Failure to Maintain Accurate Clinical Records and Notification Documentation
Penalty
Summary
The facility failed to maintain complete and accurate clinical records for a resident with severe cognitive impairment. The resident, who had a diagnosis of dementia and a Brief Interview of Mental Status (BIMS) score indicating severe impairment, was issued a Notice of Proposed Discharge (NOPD) on the same day as discharge. The NOPD was signed by both the resident and her responsible party (RP), despite the RP not being present at the facility on that day. Interviews confirmed that the RP did not sign the document and would not have used the signature shown. The Social Service Director (SSD) and Director of Nursing (DON) acknowledged that the RP was not present and that the documentation did not accurately reflect the method of notification or the actual signature process. Additionally, the facility did not accurately document the time of family notification following a witnessed fall involving the same resident. The SBAR Communication Form indicated that the resident's daughter was notified at midnight, but the DON stated this was likely incorrect, and the Licensed Vocational Nurse (LVN) could not recall the exact time of the incident or the calls made. The LVN admitted to not updating the documentation to reflect the actual time of notification and was unsure if the calls were documented in the progress notes. There was no other documentation to support the timing or occurrence of family notification. Facility policies required that all services, changes in condition, and notifications be documented completely and accurately in the resident's medical record. The failures in documentation and record-keeping resulted in the resident and her family not being able to exercise their right to appeal the discharge and had the potential to prevent the family from making informed decisions or being present during a crisis.