Inaccurate MD Notification Time Documented on Change of Condition Form
Penalty
Summary
The deficiency involves the facility’s failure to maintain accurate medical record documentation on a Change of Condition (COC) form for one resident. The resident, admitted with diagnoses including metabolic encephalopathy, UTI, epilepsy, acute kidney failure, and HTN, returned to the facility on 4/13/2025 at 4:30 p.m. after being out of the facility. The COC form for that date documented that the resident had left eye drooping and unequal pupils. An assessment by LVN 1 indicated no drooping was observed, the resident’s left eye was closed but could be opened without difficulty, and redness of the left eye was noted. LVN 1 documented on the COC form that the resident’s MD was notified of the change of condition and recorded the notification date and time as 4/13/2025 at midnight. During an interview and concurrent record review on 1/29/2026 at 3:05 p.m., the DON confirmed that the COC form showed left eye drooping and unequal pupils and acknowledged that the time documented for MD notification was not correct. The DON stated that LVN 1 should have documented the actual time the MD was called and notified of the change of condition on the COC form and that information on the COC form must be timely and accurate. Review of the facility’s policies on Change in Condition: Notification and Charting and Documentation showed that the facility requires residents, family/legal representatives, and physicians to be informed of changes in condition, and that all changes in a resident’s medical, physical, functional, or psychosocial condition be documented in an objective, complete, and accurate manner to facilitate communication among the interdisciplinary team.
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