Incomplete and Inaccurate Clinical Record Documentation for Resident with Chest Injury
Penalty
Summary
The facility failed to maintain complete and accurate clinical records for a resident who returned from a dialysis center with ecchymosis and a blood blister in the middle of the chest. The assigned LVN documented the presence of a blood-filled blister in the Event Report but omitted the ecchymosis surrounding the blister, despite having observed both. The LVN also did not write a physician's telephone order for the nurse practitioner's directive to send the resident to the emergency room for evaluation, as required by facility policy. The Director of Nursing (DON) assessed the resident the following day after being notified of the incident but did not document this assessment in the resident's clinical record, contrary to facility policy and training. Interviews confirmed that both the LVN and DON were aware of the need to document all assessments and physician orders in the electronic clinical record but failed to do so in this instance. The facility's policy requires that all services, changes in condition, and events be documented objectively and completely by licensed personnel. The resident involved had a complex medical history, including end-stage renal disease on hemodialysis, diabetes mellitus type II, anemia, gastrointestinal bleeding, and dementia. At the time of the incident, the resident was alert and able to communicate, reporting no pain from the chest bruise and blister. The lack of complete and accurate documentation regarding the resident's condition and the care provided resulted in a deficiency related to the maintenance of clinical records.