Failure to Maintain Complete and Accurate Medical Records for Adverse Event and Hospital Visit
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete, accurate, and accessible medical records for two residents. For Resident 2, an incident report documented that the resident experienced a syncopal episode on the toilet around 2:00 AM, after which a nurse checked vital signs, kept the resident up in a chair for 30 minutes, and then returned the resident to bed. The clinical record, including progress notes, did not contain any documentation of the syncopal episode, the assessment, the vital signs, or whether the provider was contacted. In an interview, the LPN responsible for the resident that night stated that a NAC reported the resident had passed out during a bowel movement on the toilet, that the resident’s color was not good, and that the resident was up and down in their wheelchair. The LPN stated they had the NAC take vital signs, which were at baseline, and that no further assessment was done beyond asking the resident questions and taking vitals. The LPN acknowledged they did not document the episode or notify the provider and stated they should have charted it but did not before the resident died at 5:30 AM. For Resident 3, the deficiency centers on missing hospital documentation following a hospital visit for reinsertion of a urinary catheter. Review of the clinical record showed there were no hospital records from that visit at the time of the initial review. When the HIM was asked to obtain the hospital records, the dictation from the hospital visit was later obtained and added to the record. In interviews, the HIM stated that nurses were usually responsible for obtaining hospital records after hospital visits, and the Interim DON stated that hospital visits and adverse events such as syncope should be documented in the clinical record and accessible. The survey findings concluded that the facility failed to ensure a system was in place to keep residents’ records complete, accurate, accessible, and systematically organized, as required by WAC 388-97-1720.
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