Incomplete and Inaccurate Clinical Documentation at Time of Resident Death
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete, accurate, and timely clinical documentation for a resident who was admitted with multiple serious medical conditions and later expired at the facility. The resident had a history of a recent hip fracture with surgical repair, Diabetes Mellitus, Dementia, Anxiety Disorder, coronary angioplasty with stents, and malignant neoplasm of the eye, among other diagnoses. A Medical Examiner’s report determined the death to be from natural causes and ruled out foul play. On the night of the resident’s death, Nurse A worked the 11:00 PM to 7:30 AM shift and had initiated subcutaneous hydration before her shift. She reported that the 3–11 nurse had told her the resident had shallow breathing and appeared pale. The nursing assistant confirmed the resident was still breathing at around 1:00 AM, and at approximately 2:30 AM the resident was found unresponsive, a code was overhead paged, and CPR was started. Nurse A acknowledged that she did not follow standards of nursing documentation: she failed to document the assessment findings prior to CPR (such as absence of pulse, blood pressure, and respirations), the time CPR was started, the time EMS arrived and took over, and when resuscitation was stopped. Her only progress note entry at 3:16 AM stated that the resident coded at approximately 2:30, that 911 was alerted, the resident was pronounced at 2:44 AM by EMS, and that the provider group and daughter were notified, without the detailed assessment and pronouncement information required by the facility’s “Death of a Resident” and “Documentation Expectations” policies. A separate documentation issue was identified with Nurse B, who completed a Sepsis Screening Evaluation in the electronic record for this resident on a date after the resident had already been deceased for several days, with no indication that the entry was a late entry or an error. The sepsis screen documented normal vital signs, no suspected infection, and no antibiotic therapy, and was electronically signed on that later date without any strike-out or late-entry notation. In interview, Nurse B stated she was unaware she had documented an assessment on the resident after death, reported she did not have access to the strike-out function, and suggested it might have been for another patient or a late entry with an incorrect date, but she could not recall the specifics. The DON confirmed that the resident had passed away before the date of Nurse B’s documented assessment and stated they were not sure what happened with that entry. These actions and omissions conflicted with the facility’s policies requiring contemporaneous, accurate documentation, proper correction of errors via strike-out or addendum, and clear identification of late entries.
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