Inaccurate EHR Documentation of Communication and Hearing Status
Penalty
Summary
The deficiency involves the facility’s failure to ensure the accuracy and completeness of the electronic health record (EHR) for one resident with significant communication and hearing impairments. The resident’s face sheet documented diagnoses including expressive language disorder, bilateral sensorineural hearing loss, dysphagia, other drug-induced secondary Parkinsonism, and a cognitive communication deficit. Multiple clinical records, including psychiatric notes, care plans, progress notes, speech therapy evaluations, physician orders, and staff interviews, consistently described the resident as nonverbal, using a notebook, whiteboard, or communication board to communicate, and having profound hearing loss or highly impaired hearing. Despite this consistent documentation and staff reports, the provider documentation within the EHR repeatedly indicated that the resident had “clear speech” and could speak without limitations on several dates. Psychiatric notes on multiple occasions stated that the resident was nonverbal and that assessments were completed via chart review and staff support. The speech therapy evaluation documented that the resident was nonverbal, had no useful hearing, and relied on a notepad to communicate, with auditory comprehension not indicated due to profound hearing loss. The care plan and progress notes also identified the resident as primarily nonverbal, using alternative communication methods, and at risk for adjustment issues related to communication challenges. Interviews with facility staff, including CNAs, an RN, a CMA, the Activities Director, the Director of Rehab, the Social Services Director, and the DON, uniformly confirmed that the resident did not speak and used written communication methods, and that the resident had significant hearing impairment or profound hearing loss. The DON acknowledged that the EHR should reflect the resident as nonverbal with hearing loss but did not, due to the conflicting provider documentation indicating clear speech. This inconsistency between provider documentation and all other clinical records and staff observations resulted in an inaccurate and incomplete EHR for the resident’s communication and hearing status.
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