Failure to Maintain Accurate and Complete Medical Record Documentation
Penalty
Summary
The facility failed to maintain accurate and complete documentation regarding a resident's change of status. According to the facility's own policy, all services provided, progress toward care plan goals, and any changes in a resident's condition must be documented in the medical record to facilitate communication among the interdisciplinary team. In the case reviewed, a resident with diagnoses including pneumonia, COPD, acute respiratory failure with hypoxia, and severe protein-calorie malnutrition experienced significant changes in condition, such as low oxygen saturation, confusion, refusal of medications and meals, and removal of oxygen. While some nursing actions and observations were recorded in a written statement provided by the Nursing Home Administrator, these were not included in the resident's permanent clinical record. Further review of the clinical record revealed a lack of documentation regarding nursing follow-up care, treatment, and physician notification related to the resident's low oxygen saturations and confusion. The Nursing Home Administrator confirmed that the provided nursing documentation was not part of the official clinical record and that there was no evidence of communication between the interdisciplinary team about the resident's condition and response to care. This failure to document and maintain complete records was found to be out of compliance with both facility policy and state regulations.