Incomplete and Inaccurate Documentation During Resident Change in Condition
Penalty
Summary
The deficiency involves incomplete and inaccurate medical record documentation for one resident who had serious medical conditions, including acute pulmonary edema, ESRD, and severe sepsis with septic shock. The resident was dependent on staff for ADLs and could make needs known but could not make medical decisions. On the date of the incident, a Change in Condition Evaluation (CICE) form was initiated at 9:35 PM for altered mental status, but it only contained previously recorded vital signs from earlier that afternoon and did not include current vital signs at the time of the change in condition. The CICE form also lacked completed assessments of the resident’s behavioral, respiratory, cardiovascular, abdominal/gastrointestinal, genitourinary, and neurological status, and there was no documentation that the primary physician had been notified of the change in condition. A progress note by an LVN, timed at 11 PM, documented that at 9:30 PM the resident was found pale with shallow breathing and an O2 sat of 88% on 2 L/min via NC, and that the RN supervisor reassessed the resident and called 911 at 7:37 PM, with paramedics arriving within 5 minutes. This documentation conflicted with the RN’s later interview statements about the timing of events. In an interview, the RN stated that around 9 PM the LVN reported the resident was breathing fast with an O2 sat of 86%, that the RN placed the resident on a non-rebreather mask, the O2 sat increased to 90%, 911 was called after 9 PM, and the resident was placed on continuous O2 sat and heart rate monitoring while the RN remained at the bedside until paramedics arrived. None of the RN’s assessment findings, the initiation of the non-rebreather mask, the continuous monitoring, or the physician notification were documented in the resident’s medical record. The DON confirmed on review that the CICE form was incomplete and emphasized the importance of accurate and complete documentation, as required by the facility’s policies on documentation and notification of changes.
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