Failure to Maintain Accurate and Complete Medical Records
Penalty
Summary
The facility failed to maintain accurate and complete medical records for two of three sampled residents. For one resident, there was a discrepancy between the code status documented by an LVN on the Physician Orders for Life-Sustaining Treatment (POLST) form and the physician's order. The POLST indicated that resuscitation/CPR should be attempted, while the physician's order documented a Do Not Resuscitate (DNR) status. The LVN acknowledged mistakenly documenting DNR in the physician's order instead of full code, despite the resident and family requesting full code and the POLST being signed accordingly. This inconsistency was confirmed by the Social Service Designee, Assistant Director of Nursing (ADON), and Director of Nursing (DON), all of whom noted the importance of accurate code status documentation for proper care delivery. Additionally, the same resident experienced an unresponsive episode during which the LVN who first discovered the resident did not document her observations or interventions in the medical record. Although the LVN initiated CPR and called for emergency assistance, there was no nursing note from her detailing the events from the start of her shift until the resident was found unresponsive. The DON and RN involved confirmed that the LVN should have documented her findings and actions, as required by facility policy, to ensure a complete and accurate account of the resident's condition and care provided. For another resident, the facility failed to document the events surrounding the resident's hospital leave. The electronic health record indicated the resident was on hospital leave on two occasions, but there were no progress notes or SBAR-Change of Condition forms documenting the transfer to the hospital or the reason for the leave. The ADON and DON both stated that there should have been documentation of the resident's status, the transfer, and communication with the physician and family. Facility policy requires that all changes in a resident's condition, treatments, and events be documented in the medical record to facilitate communication and continuity of care.