Inaccurate and Misattributed Documentation of Code Blue Event
Penalty
Summary
The deficiency involves the facility’s failure to ensure that medical records were accurately documented in accordance with professional standards for one resident. The resident was an adult male admitted with malignant neoplasm of the tonsil and lymph node, dysphagia, and pneumonitis. On the morning in question, an IDT progress note authored by the Nursing Home Administrator (NHA) documented that at 9:15 AM a CNA entered the resident’s room to obtain vital signs and found the resident unresponsive, with eyes and mouth open, no response to touch or name, dry oral mucosa, and mottling from the waist to the feet. The note further stated that RN Q assessed the resident by checking for a pulse, feeling the ankles, and listening for respirations with a stethoscope for one minute, and that at 9:24 AM RN Q notified the NHA and DON that the resident was deceased and that it was an irreversible death. During a subsequent telephone interview, RN Q confirmed she was the primary nurse responsible for the resident’s care that morning and that she ultimately called a code blue. When asked if the event was documented in the resident’s medical chart, RN Q stated she remembered charting it somewhere in the EMR but was unsure of the exact location. A separate report titled “#1154 Code Blue,” dated the same morning at 9:30 AM, listed the resident and identified the DON as the person preparing the report. In an interview, the DON stated she was not in the facility at the time of the incident and had not documented that report, assuming instead that it was RN Q’s documentation and suggesting that another staff member may have opened the assessment for RN Q because RN Q did not know how to do so herself. In another interview, the NHA stated that all staff are required to document under their own name in the medical record, highlighting that the code blue documentation was not accurately attributed to the staff member who provided care.
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