Failure to Document and Monitor Change in Condition After Fall
Penalty
Summary
The deficiency involves the facility’s failure to ensure nursing care and services met professional standards of quality through complete and timely documentation and monitoring following a change in condition. A hospice resident with vascular dementia, anemia, physical debility, and COPD experienced an unwitnessed fall, documented on a Change of Condition Evaluation (COC) as occurring without injury or swelling, though the resident complained of pain in the left elbow and left hip. The responsible party and physician were notified and pain medication was ordered. Nursing progress notes indicated that paramedics were called and the responsible party declined hospital transfer and x‑ray at that time. According to the facility’s policy and the ANA guidance on nursing documentation, clear, accurate, and accessible documentation is essential for communication and continuity of care. In the days following the fall, a CNA reported that there was no swelling or discoloration immediately after the fall and that they continued to care for the resident until slight swelling of the left hip was observed several days later, which was reported to the nurse. On that date, nursing notes indicated slight swelling of the left hip and that an x‑ray was taken after an order from the hospice physician. However, there was no documentation of the responsible party’s refusal to send the resident to the hospital, and no follow‑up documentation was found to show that the swollen left hip was monitored. One LVN acknowledged not initiating a new electronic COC when the swelling was observed, and another LVN stated that without a COC, the required 72‑hour follow‑up monitoring and documentation in the electronic system would not occur. The ADON confirmed the observation of mild left hip swelling and acknowledged the missing COC and lack of 72‑hour follow‑up monitoring and documentation, and was unable to provide proof that the swelling was monitored by nurses, contrary to the facility’s Change in Condition Reporting policy requiring assessment and documentation every shift for at least 72 hours after an acute medical change.
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