Failure to Document 72-Hour Monitoring After Change in Condition
Penalty
Summary
The facility failed to implement and document a complete care plan for a resident who experienced a change in condition after pulling out a gastrostomy tube (G-tube). The resident's G-tube was reinserted at bedside and the resident was placed on 72-hour change in condition (CIC) monitoring. However, review of the resident's progress notes revealed missing documentation of monitoring: one entry was missing on one day and three entries were missing on another day during the 72-hour period. The Assistant Director of Nursing confirmed that monitoring should have been documented on all three nursing shifts as per facility policy. The facility's policy requires nurses to record information related to changes in a resident's condition in the medical record.