Failure to Document Change of Condition After Seizure Episodes
Penalty
Summary
The facility failed to maintain complete and accurate medical records for one resident by not ensuring that licensed nurses documented the resident's change of condition (COC) following three consecutive seizure episodes. The resident, who had diagnoses including type 2 diabetes mellitus, other specified disorders of the brain, and convulsions, was admitted with physician orders to monitor and document seizure activity every shift and notify the attending physician if seizures occurred. Despite these orders, there was no documented evidence that an SBAR (Situation, Background, Appearance, and Review) form was created for the seizure episodes, and the progress notes lacked complete documentation of the assessments performed after each event. Interviews with nursing staff and the DON confirmed that the required documentation, including the date, time, pertinent details of the event, subsequent assessments, and notifications to the physician and family, was not completed as per facility policy. The facility's policies on change in condition and completion and correction of medical records require prompt, complete, and accurate entries reflecting medically relevant information. The failure to document the resident's change of condition and related assessments resulted in incomplete and inaccurate medical records.