Failure to Document DON Assessment in Resident Medical Record
Penalty
Summary
A deficiency occurred when the Director of Nursing (DON) failed to document an assessment and observation of a resident with severe cognitive impairment and multiple complex medical diagnoses, including pneumonitis, dysphagia, and respiratory failure. The facility's policy required that all services, changes in condition, and objective observations be documented in the resident's medical record to ensure complete and accurate communication among the interdisciplinary team. On the date in question, therapy staff expressed concerns about the resident's respiratory status and swelling, prompting the DON to assess the resident. The DON verbally reported the assessment findings to the registered nurse (RN) but did not enter any documentation of the assessment or observations into the resident's medical record. Subsequent interviews confirmed that the DON acknowledged the lack of documentation and that the assessment was only communicated verbally. The resident's medical record was missing this critical information, despite the facility's policy and the need for accurate records to reflect changes in the resident's condition. The omission was identified during a surveyor's review of the medical record and staff interviews, which also revealed that the resident was later sent to the hospital and passed away. The failure to document the DON's assessment constituted a lack of complete and accurate medical records for the resident.