Failure to Document Physician Notification and Follow-Up After Change in Condition
Penalty
Summary
The facility failed to ensure that medical records were complete and accurately documented for a resident who experienced a change in condition. Facility policy titled "Notification of Changes in Resident Condition and Treatment Changes" required nursing staff to notify the physician of changes, accidents, and injuries, obtain treatment and diagnostic orders, and document findings and notifications in the nurses' notes. The resident was admitted with diagnoses including cognitive communication deficits and congestive heart failure, and a subsequent MDS confirmed these diagnoses remained current. A change in condition report documented that the resident was observed with altered mental status on a specified date. Despite the documented change in condition, the resident’s nurse progress notes did not contain any documentation of physician notification, follow-up assessments, or treatment plans related to this event. An RN reported that the physician had been notified of the change in condition via text message from the RN’s personal phone but acknowledged that this communication was not documented in the medical record. The DON confirmed that the medical record lacked documentation of the physician notification and related follow-up, resulting in incomplete and inaccurate clinical records for this resident in violation of 28 Pa. Code 211.5(f)(g)(h).
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