Failure to Document Change in Condition and Maintain Accurate Clinical Records
Penalty
Summary
The facility failed to maintain complete and accurate clinical records for a resident who was dependent on staff for all activities of daily living and had significant medical conditions, including acute respiratory failure, chronic kidney disease, and a tracheostomy. On a specific date, maggots were discovered around the resident's tracheostomy site, but this significant change in condition was not documented in the resident's electronic health record (EHR). The nurse who identified the issue did not complete the required SBAR communication tool, did not document the incident in the nursing progress notes, and did not submit a change of condition report as required by facility policy. Interviews with facility staff confirmed that the presence of maggots was verbally reported to the physician and the Director of Nursing (DON), but there was no written documentation in the EHR or in the physician's order summary to accurately reflect the resident's condition. The DON acknowledged that the omission of this information from the medical record and transfer order was inappropriate and that an incident report, progress notes, and care plan update should have been completed. The nurse involved also admitted to not informing the resident's family of the specific reason for the hospital transfer and stated that her actions were not consistent with facility policy or nursing standards of practice. A review of facility policies and job descriptions confirmed that nurses are required to document changes in a resident's condition and ensure timely and appropriate documentation of care activities. The lack of documentation regarding the discovery of maggots and the resident's change in condition resulted in incomplete clinical records and a failure to follow established protocols for reporting and escalating significant health concerns.