Failure to Document ENT Referral and Communication
Penalty
Summary
The facility failed to maintain complete and accurate documentation regarding an ENT referral for a resident with severe cognitive impairment and multiple psychiatric diagnoses, including Alzheimer's Disease, dementia, and behavioral issues. After the resident experienced a fall resulting in a nasal fracture, emergency department discharge instructions specified that the resident should be re-evaluated by ENT within the following week. However, a review of the resident's electronic health record (EHR) did not show any documentation of communication or referral to ENT as instructed. Interviews with the DON revealed that calls were made to the ENT clinic regarding the referral, and follow-up communication occurred, but these actions were not documented in the resident's EHR at the time. The DON acknowledged the lack of documentation for both the ENT referral and communication with the resident's family. A late entry progress note was later created to reflect the communication, but this was after the deficiency was identified.