Failure to Accurately Document Resident Assessment and Physician Communication During Change in Condition
Penalty
Summary
The deficiency involves the facility’s failure to maintain accurate and complete clinical documentation in accordance with its own policy and accepted professional standards for one resident. The resident, an older male with pulmonary fibrosis, chronic hypoxic hypercapnic respiratory failure, and COPD, was admitted from the hospital with ongoing respiratory issues, including shortness of breath, worsening hypoxia, and confusion. On admission, he had orders for continuous oxygen at 2–6 L/min via nasal cannula with oxygen saturation monitoring each shift, and scheduled Ipratropium-Albuterol inhalation for shortness of breath. An IDT nursing note documented that he was admitted following episodes of altered mental status, hypoxia, pulmonary fibrosis, and COPD, and that he was on 4–6 L/min of oxygen. On the day of admission, the resident experienced a change in condition with worsening hypoxia. An SBAR form documented that his oxygen saturation was 74% via nasal cannula and that his son reported the resident was not receiving enough oxygen through the concentrator and requested that he be sent out. An IDT nursing note by an LVN recorded that the resident complained of hypoxia and shortness of breath, with vital signs including BP 157/83, HR 122, respirations 30, and oxygen at 6 L/min, and that the physician was notified and ordered transfer to the ER via EMS, with the resident transferred to the hospital and a family member at bedside. However, during interview, this LVN stated she had assessed the resident when he was yelling that he could not breathe and arranged transfer to the ER, but she acknowledged she had not documented her assessment in the clinical record on that day and had not documented that the family member was in the room when the resident was transported. Another LVN reported that she made two telephone calls to the resident’s attending physician on the day of admission: one to confirm medication orders upon admission and a second to report that the resident had been sent to the hospital via EMS due to a change in condition. She stated that licensed staff had been trained to document in the clinical record when they called the physician to obtain orders or report changes in condition, but she did not document either of these calls in the resident’s record, citing multiple admissions that day and lack of time. The DON confirmed that licensed staff were trained to document resident assessments and physician or NP communications in the electronic record. Review of the facility’s Clinical Documentation policy showed that documentation was to be accurate, timely, reflective of care provided, and completed as close to the time of care as possible, including documentation of assessments and exceptions when care does not occur as planned, which was not followed in this case.
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