F0842

D

Failure to Document Change of Condition and NP Clinical Rationale for STAT Chest X-Ray

North Hollywood, California Survey Completed on 01-08-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to maintain a complete and accurate medical record for one resident by not documenting a clear change of condition (COC) and related medical decision-making. The resident was admitted with chronic respiratory failure, a tracheostomy, ventilator dependence, and an anoxic brain injury requiring total care and constant supervision. On the date in question, the order summary showed that a nurse practitioner (NP 1) gave a STAT chest x-ray order by phone at 6:08 p.m. However, there was no COC documentation by the responsible RN (RN 2) describing what occurred with the resident that led to this STAT order. The only contemporaneous entry was a respiratory therapy note at 6:28 p.m. indicating tachycardia and tachypnea, which RN 1 and the DON both identified as changes from baseline that should have been documented as a COC.

The facility’s Director of Nursing (DON) confirmed that there was no COC documentation in the electronic medical record describing the signs or symptoms present on that date that prompted the STAT chest x-ray. The DON stated that a COC is anything that differs from a resident’s baseline, such as abnormal vital signs or breathing, and emphasized that timely COC documentation is important to communicate significant events and ordered care to subsequent shifts and to avoid duplicate orders. The facility’s policy on Documentation Principles required that health records be current, detailed, and consistent with good medical and professional practice, and that entries be accurate, timely, specific, concise, clear, and descriptive. The absence of a COC entry for this event meant the record did not meet these stated standards.

In addition, the NP did not timely document a progress or medical note explaining the clinical indications for the STAT chest x-ray or whether the attending physician was notified. NP 1 stated that typically the attending physician is updated about a resident’s COC and that the physician completes progress notes, while NP 1 documents certain procedures and family conversations. Review of the resident’s record with RN 1 showed no NP progress note on the date of the STAT order or the following day. Instead, NP 1 entered a Medical Professional Note six days later stating the patient had tachycardia and was placed on backup ventilator settings due to work of breathing, without clearly specifying whether these findings occurred on the date of the STAT order or on the date of documentation, and without indicating if the attending physician had been informed. The DON stated that, as a professional standard, a nurse practitioner should document when contacted about a COC requiring medical interventions and that NP documentation must be clear, detailed, and separate from other nurses’ notes, reinforcing that if there is no documentation, it is considered not done.