Incomplete Documentation of Change of Condition and Oxygen Administration
Penalty
Summary
The facility failed to maintain complete and accurate medical records for one resident by not documenting essential information during a change of condition event. Specifically, the Change of Condition (COC) form for the resident did not include documentation of oxygen administration details or comprehensive monitoring of vital signs, such as the amount and timing of oxygen provided. This omission was confirmed during interviews with both the registered nurse involved and the Director of Nursing, who acknowledged that the documentation was incomplete and did not accurately reflect the care and treatment provided. The resident in question had a history of anemia, chronic kidney disease, and urinary tract infection, and was assessed as having moderately impaired cognitive skills, requiring varying levels of assistance with daily activities. On the day of the incident, the resident experienced tachycardia, hypertension, and episodes of oxygen desaturation, ultimately requiring transfer to an acute care hospital. Despite these significant changes in condition, the medical record lacked detailed documentation of the resident's vital signs and the specifics of oxygen therapy administered during the event. Facility policies reviewed indicated that all services, treatments, and changes in a resident's condition should be thoroughly documented in the medical record to facilitate communication among the care team. However, the COC form for this resident did not meet these standards, as it failed to include care-specific details about the treatments performed and the resident's response to those interventions.