Incomplete and Missing Documentation of Resident Death and Skin Breakdown
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurate electronic health records in accordance with professional standards and facility policy. For one resident with multiple complex medical conditions, including type 2 diabetes mellitus, metabolic encephalopathy, cardiomegaly, morbid obesity, and stage 2 chronic kidney disease, the record showed he was cognitively intact, not on hospice, and a full code. The only nursing progress note around the time of his death documented that a funeral home arrived to retrieve his remains, with no documentation of the events leading up to his death. A regional RN confirmed that the events leading to the resident’s death were not documented in the medical record. For another resident with Alzheimer’s disease and memory deficit following cerebral infarction, the MDS showed impaired cognition, need for supervision with ADLs, frequent incontinence, and no skin issues. Nursing notes documented that this resident was sent to the ER due to a change in condition, and the hospital later notified the facility that the resident had a coccyx wound. There were no prior notes in the record regarding any skin breakdown. An internal investigation found that during shift change earlier that day, staff had identified a bruised-like area on the coccyx and placed a foam pad, but this skin change and the intervention were never documented in the electronic health record. Facility policy required timely and accurate documentation, including opening a wound event, assessing and documenting the wound, and related notifications and orders, which was not followed in this case.
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