Incomplete Medical Record Documentation for Resident with Tracheostomy
Penalty
Summary
The facility failed to maintain a complete and accurate medical record for one resident with significant medical needs, including acute respiratory failure with hypoxia, anoxic brain damage, and congestive heart failure. The resident was documented as being in a persistent vegetative state with a tracheostomy. Review of the electronic medical record revealed missing documentation in the Treatment Administration Record (TAR) for several critical care tasks, including assessment for suctioning every two hours and as needed, cleansing of the tracheostomy site every shift, and changing or cleaning the inner cannula every 12 hours. Specific dates and times were identified where the required documentation was absent, as evidenced by empty boxes with no nurse initials. Interviews with a registered nurse and the Director of Nursing confirmed the missing documentation on the TARs for the months reviewed. Both staff members acknowledged that the absence of documentation meant the tasks may not have been completed as ordered, as the process requires nurses to sign off on each task as it is performed. The deficiency was limited to the lack of documentation for the required treatments and care tasks for the resident during the specified period.