Inaccurate Clinical Record Due to Erroneous Physician Documentation
Penalty
Summary
Facility staff failed to maintain an accurate clinical record for one resident when the attending physician erroneously documented a recommendation for a CIWA (Clinical Institute Withdrawal Assessment for Alcohol) protocol assessment, which facility staff are not trained to perform. The resident in question had a history of debility, alcohol dependence, Parkinson's disease, worsening weakness, unsteady gait, unintentional weight loss, and multiple falls. The physician's progress note indicated a plan to place the resident on the CIWA protocol due to suspected alcohol withdrawal, despite conflicting reports about the resident's last alcohol use. A review of the resident's clinical record did not show any evidence that CIWA assessments were performed following the physician's documentation. During interviews, the DON confirmed that facility staff do not perform CIWA assessments, and the attending physician acknowledged that the recommendation was a mistake, stating that such assessments are not typically conducted in LTC facilities. The facility's policy requires that documentation in the medical record be accurate, relevant, and complete, which was not met in this instance.