Failure to Document Resident Assessments Per Shift
Penalty
Summary
Licensed Vocational Nurses (LVNs) failed to accurately document daily narrative charting during each shift for a resident with complex medical needs, specifically on two dates. The facility's policy and procedure required documentation during each shift, including patient assessment and the status of medical devices such as IV lines, tracheostomy, and gastrostomy tubes. However, record review and staff interviews confirmed that narrative charting was missing for both the night and day shifts on the specified dates. Staff, including LVNs and the Charge Nurse, acknowledged the absence of required documentation and emphasized the importance of maintaining accurate records for resident care. The resident involved had a medical history of chronic respiratory failure, Alzheimer's disease, COPD, and had both a tracheostomy and gastrostomy in place. During observation, the resident was found awake, resting, and appeared confused, with fluctuating capacity to understand. The lack of documentation resulted in the resident's medical record containing inaccurate information regarding patient assessment, which had the potential to affect the provision of care. The deficiency was identified through interviews, record review, and observation, confirming non-compliance with the facility's documentation policy.