Failure to Accurately Document and Communicate Resident's Acute Condition Change
Penalty
Summary
The facility failed to maintain a complete and accurate medical record for a resident who had a history of right femur fracture and hip dislocation and required assistance with personal care. On the morning of the incident, the resident experienced acute pain and a possible hip dislocation after attempting to retrieve an abductor pillow. The Licensed Vocational Nurse (LVN) on duty did not document the resident's acute condition change on the day it occurred. Instead, the LVN created the Change in Condition Evaluation (CIC) document the following day, and the documentation inaccurately recorded the event as having started on the later date. Additionally, the documentation incorrectly indicated that the attending physician was notified at a time when there was no response from the physician during the LVN's shift. The LVN also failed to report the resident's complaint of pain and possible hip dislocation to the Registered Nurse (RN) supervisor during shift change, and the CIC was not completed before the LVN left the facility. As a result, the RN supervisor was unaware of the resident's acute condition change. The facility's policies required timely, objective, complete, and accurate documentation of acute condition changes, including reporting to the appropriate staff and physician, which was not followed in this instance.