Inaccurate and Incomplete Documentation of Respiratory Status and Change in Condition
Penalty
Summary
The deficiency involves failures in accurate and complete documentation of a resident’s respiratory status and change in condition. The resident was admitted with acute and chronic respiratory failure, pneumonia, a tracheostomy, and ventilator dependence, and had documented moderate cognitive impairment and dependence on staff for most activities of daily living. The resident’s History and Physical noted coarse breath sounds, and the facility’s policies on Charting and Documentation and Change in a Resident’s Condition or Status required that all services, assessments, and changes in condition be documented objectively, completely, and accurately in the medical record. On the date of the incident, the Licensed Nurse Record for the resident showed a blank section where the breath sound assessment should have been documented. During interview, the LVN assigned to the resident stated that he had assessed the resident’s breath sounds but did not document his findings in either the Licensed Nurse Record or the Progress Notes, leaving the breath sound section blank. He acknowledged that, per facility policy, all observations and services provided, including breath sound assessments, should have been documented to facilitate communication among the care team and that inaccurate documentation prevents the team from knowing the resident’s condition. The resident’s Progress Notes and Change of Condition (COC) form for the same date contained conflicting times for the onset of respiratory distress and unresponsiveness. The Progress Notes, written by a respiratory therapist, indicated that the resident experienced respiratory distress and required emergency transport at 4:15 p.m., while the COC indicated the resident was found unresponsive and pulseless at 4:23 p.m., and the paramedic run sheet showed dispatch at 4:26 p.m. The Respiratory Manager stated that the respiratory therapist likely wrote the Progress Note later in the evening but inaccurately timed it as 4:15 p.m. instead of the actual time it was written, and the DON confirmed that the records were confusing and unclear, with the Progress Note time being inaccurate. These discrepancies and omissions resulted in an inaccurate and incomplete medical record for the resident.
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