Failure to Document Influenza Testing in Resident Medical Records
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurate medical records when the Infection Preventionist (IP) performed influenza testing on several residents and did not document these tests in the electronic medical record (EMR). The facility’s policy on Charting and Documentation requires that all services provided to residents, including treatments or services performed, be documented in the medical record with complete and accurate details such as date, time, provider, and how the resident tolerated the procedure. The IP’s job description states that the IP is accountable for surveillance of healthcare-acquired and community-acquired infections. Despite these requirements, the IP acknowledged that multiple influenza tests she performed were not documented in the EMR, resulting in incomplete medical records. Record reviews showed that several residents had documented changes in condition and positive influenza A results, but not all tests performed by the IP were recorded. One resident with dementia and anxiety had a change in condition note indicating a positive influenza A test, nasal congestion, and a nonproductive cough. Another resident with malignant neoplasm of the lung and secondary neoplasm of the brain had a change in condition with shaking, weakness, altered responsiveness, and low oxygen saturation, and the IP stated she tested this resident for influenza before transfer to an acute care hospital but did not document the test. The IP also stated she tested this resident’s roommate, who had diagnoses including Type 2 diabetes mellitus, hypertension, and muscle weakness, but could not find documentation of that influenza test in the EMR. Additional residents were involved in the undocumented testing. One resident with Parkinsonism, Type 2 diabetes mellitus, and anxiety developed respiratory symptoms with a nonproductive cough, and the IP stated she tested this resident for influenza but confirmed there was no documentation of the test in the EMR. Another resident with hemiplegia and hemiparesis following intracerebral hemorrhage, respiratory failure, and hypoxia developed a nonproductive cough, and the IP recalled testing this resident but found no documentation of the test or results in the EMR. During an interview, the DON and ADON confirmed they were present when the IP tested residents for influenza and stated that if tests were not documented, they were considered not done, and that the medical record was not complete without documentation of the influenza tests. They further stated it was the IP’s responsibility, not the charge nurse’s, to document the tests she performed.
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