Incomplete and Delayed Medical Record Documentation Following Change in Condition
Penalty
Summary
The facility failed to ensure complete and accessible medical record documentation for one resident with multiple serious diagnoses, including chronic respiratory failure, COPD, and pneumonia. The resident experienced a significant change in condition, evidenced by an elevated oral temperature of 102.9°F, which was documented by an LPN. However, the medical record lacked evidence of timely and complete documentation of nursing interventions, follow-up monitoring, and provider notification related to this change in condition. Although a physician progress note acknowledged the fever and recommended monitoring and Tylenol as needed, this note was not transferred to the facility's software until several days later, and the Director of Nursing was unable to clarify the timing of the note's entry. Additionally, the DON refused to provide a copy of the note, citing HIPAA privacy, despite policy allowing surveyor access. Interviews with nursing staff and the physician confirmed that a temperature above 100.3°F should have triggered provider notification, interventions, and documentation, but the medical record did not contain evidence of these actions. The physician also expected documentation of interventions and rechecking of the temperature, but did not recall being updated by the covering physician. The facility's policies required documentation of changes in condition and provider notification, but there was no evidence in the record that these requirements were met. Furthermore, the physician services policy did not address accountability for timely electronic documentation or software transfers.