Inaccurate Advance Documentation of Isolation Room Transfer
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident’s medical record was accurately documented in accordance with facility policy. The resident had a history that included cerebral ischemia, spinal stenosis, and paroxysmal atrial fibrillation, and had been recently re-admitted after treatment for a urinary tract infection. An MDS assessment indicated the resident required maximal assistance with eating, personal hygiene, and upper body dressing, and was dependent for toileting hygiene and bathing. These details establish the resident’s clinical status and functional dependence at the time of the events. On the day in question, the resident experienced several episodes of diarrhea, and a stool sample was collected and later tested positive for C. difficile. Following receipt of the positive test result, nursing staff determined the resident needed to be moved to a private room and placed on contact isolation. LVN 1 stated that the new private room still needed to be cleaned before the resident could be transferred and reported that the actual transfer occurred around midday. CNA 1 similarly recalled that housekeeping had to clean the new room first and that the transfer occurred shortly before CNA 1’s lunch break at approximately 11:30 a.m. However, review of the electronic medical record showed that an Infection Note dated the same day was entered at 9:07 a.m., indicating that the resident had already been placed in a private room. When questioned, LVN 1 acknowledged that the note was likely completed before the transfer actually occurred and that the documentation was inaccurate at the time it was entered. The DON confirmed that licensed nurses are expected to chart what they have actually done and not to document events in advance, referencing the facility’s policy on Completion & Correction, which states that entries must be recorded as events occur and that an event is never to be documented before it happens. This sequence of actions resulted in an inaccurate medical record for the resident.
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