Failure to Document Resident’s Acute Change in Condition and Cardiac Symptoms
Penalty
Summary
The deficiency involves the facility’s failure to maintain a complete and accurate medical record for a resident who experienced an acute change in condition. The resident, admitted with diagnoses including cerebral infarction, COPD, and acute respiratory failure with hypoxia, had intact cognition as shown by a BIMS score of 15. On the date in question, there was no nursing documentation between 11:00 A.M. and 10:55 P.M. regarding the resident’s complaints of being shocked and screaming in pain, despite multiple reports that these symptoms occurred throughout the day. According to interviews, a day-shift LPN reported that the resident was screaming and saying that a man or the bed was shocking him. Believing the resident might have a UTI because he “was not making any sense,” the LPN unplugged and checked the bed, took vital signs, and wrote a note in the provider’s binder for follow-up, but did not document the assessment or the resident’s complaints in the medical record and did not notify a physician. The LPN also stated she did not know the resident had an ICD. Later, an RN who relieved the day-shift nurse received report that the resident had been screaming all day about being shocked. When the resident again screamed out and reported being shocked by his pacemaker, the RN assessed him, noted an irregular and elevated heart rhythm, and attempted to contact the on-call provider, but the first related entry in the medical record was not made until 10:56 P.M. Subsequently, the night-shift LPN received report that the resident had been screaming in pain most of the day due to being shocked. About an hour into that shift, the resident again screamed out in pain, was assessed, and EMS was called. EMS documented that the resident complained of shocking chest pain and was in A-fib with RVR, and he was transported to the hospital. Hospital records showed the resident reported repeated ICD firings and had a significant cardiac history including CAD from ischemic cardiomyopathy, low ejection fraction, prior CABG, and ICD placement, and he required cardiology consultation, initiation of amiodarone, and ICU admission. The DON confirmed that staff are required by policy to document changes in condition in the medical record and verified that the resident’s record lacked documentation from the day-shift LPN regarding the acute change in condition.
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