Incomplete Documentation of Lice Assessment and Treatment
Penalty
Summary
Facility staff failed to ensure a complete and accurate clinical record for one resident who was admitted with multiple diagnoses, including schizoaffective disorder, hypertension, insomnia, protein-calorie nutrition issues, and dysphagia. The resident was assessed as cognitively intact. Physician orders were documented for the treatment of head lice, including the use of a RID Super Max 5-in-1 kit, daily nit combing, and contact precautions, with treatment initiated and later discontinued within a specified period. Despite the initiation of lice treatment, the clinical record lacked documentation regarding the assessment of head lice, associated symptoms, or notification to the provider. Interviews with staff revealed that the CNA reported signs of lice to the LPN supervisor, who stated that the provider was notified and treatment started immediately. However, both the infection preventionist and the unit manager acknowledged that there should have been documentation of the assessment, provider notification, orders, and actions taken, but no such note was entered in the clinical record.