Failure to Document Resident Assessment After Ants Found on Resident
Penalty
Summary
The facility failed to ensure accurate documentation in the medical record for a resident who was found with ants on his body while lying in bed. The resident, a 65-year-old man with diagnoses including hemiplegia, COPD, diabetes, sepsis, and dementia, was under hospice care. On the morning of the incident, an LVN discovered two ants on the resident—one on his forehead and one on his throat, with food deposits present on his gown and bed. The LVN performed a quick assessment and found no bites, then verbally reported the incident to the DON, but did not document the event or her assessment in the electronic medical record (EMR). The LVN stated she was instructed by the ADON not to document the incident, as there were no bites or harm, and no incident report was made. Further review revealed that the DON also assessed the resident and found no injuries, but documented his findings only in a Standards of Care book, which is not part of the official medical record. The ADM was aware of ants being found in the resident's room but was not informed that ants had been found on the resident himself. The facility's policy requires that all services, changes in condition, and incidents involving residents be documented in the medical record. However, no documentation of the incident or assessments was found in the resident's EMR, constituting a failure to maintain accurate and complete medical records as required.