Inaccurate Documentation of Change in Condition and Notifications
Penalty
Summary
The deficiency involves the facility’s failure to maintain an accurate health record for a resident who experienced a change in condition. The resident had moderately impaired cognition with a BIMS score of 12, and diagnoses including diabetes mellitus, partial paralysis, and non-traumatic brain dysfunction. The resident required varying levels of assistance with activities of daily living and had a care plan directing staff to involve her family in decisions and medical updates. On the day of the incident, an LPN attempted to wake the resident, who was lethargic and only responded after multiple taps to her arm. The resident’s temperature was obtained by a CMA and found to be 100.4°F, and the LPN instructed the CMA to administer Tylenol. The resident refused the Tylenol, pulling her head back and saying “no” twice. The LPN then directed a CNA to return the resident to her room. A nurse’s progress note entered at 12:05 PM documented that the resident was semi-responsive, responded to touch and voice only, had a temperature of 100.4°F, and refused Tylenol. The LPN left the unit for lunch at 12:19 PM and returned at 1:25 PM, stating she did not perform any work-related duties while at lunch. She later confirmed that the resident’s condition constituted a change in condition and acknowledged that a change-of-condition form should have been completed at that time. An eINTERACT Change in Condition Evaluation dated the same day documented family and provider notification at 1:00 PM, a time when the LPN reported she was at lunch. The ADON stated staff should not be backdating and should accurately record events to reflect the time they occurred. Facility policy on documentation required each resident’s medical record to be complete, accurate, and timely, containing an accurate representation of the resident’s actual experiences, which was not followed in this instance.
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