Failure to Accurately Document Notification Time in Resident Medical Record
Penalty
Summary
The facility failed to maintain an accurate and complete medical record for one resident by not ensuring the correct time of notification was documented following an alleged sexual interaction. The resident, who had a history of epilepsy, chronic pain syndrome, and depression, was admitted with the capacity to make decisions, but later assessments indicated severely impaired cognitive skills. On the date of the incident, the eInteract Change in Condition Evaluation documented that the responsible party was notified at a time prior to the actual event, which was not possible according to the Director of Nursing (DON). The DON confirmed that the documentation of the notification time was incorrect and acknowledged that such errors could create confusion during incidents. Interviews with facility staff, including the DON and Administrator, confirmed the discrepancy in the recorded notification time. The facility's policy required licensed nurses to document the time and name of the individual notified in the event of a change in condition. The inaccurate documentation in the resident's medical record did not align with this policy and resulted in the record containing incorrect information regarding the notification of the responsible party.