Failure to Document Resident Deaths and Notifications in Medical Records
Penalty
Summary
The facility failed to maintain complete and accurate medical records for two residents who died while under care. For one resident, a female with diagnoses including malignant neoplasm of the brain, epilepsy, and altered mental status, the medical record lacked documentation of the physician discharge summary, pronouncement of death, notification of local law enforcement, and disposition of the body. The only progress note entry after her death was made by an LVN, who stated that hospice was notified and instructed not to call the family until their arrival, with no further documentation of subsequent actions or notifications. For the second resident, a male with diagnoses including senile degeneration of the brain, chronic respiratory failure, and anxiety disorder, the medical record did not contain documentation of the resident's death, pronouncement of death, notification of required entities, or disposition of the body. The progress notes only reflected the resident's move to a private room due to decline and a later entry about equipment pickup, with no entries about the death event itself. Interviews with nursing staff revealed that the RN on duty at the time of death pronounced the resident, notified the DON, family, hospice, and funeral home, and received a police case number, but failed to document these actions in the medical record. The DON confirmed that staff are expected to document all notifications, the resident's decline, expiration, vital signs, and interactions with hospice or law enforcement, as well as the pronouncement of death and disposition of the body. The facility's policy requires that each resident's medical record accurately reflect their experiences and include sufficient information to provide a complete picture of their progress, but this was not followed in these cases.