Inaccurate Documentation of Nicotine Dependence Status in Resident Medical Record
Penalty
Summary
The deficiency involves the facility’s failure to maintain a complete and accurate medical record for one cognitively intact resident with a history of centrilobular emphysema and other chronic conditions. Hospital admission records documented the resident’s social history as a current cigarette smoker on some days, and a later CT chest lung screening documented nicotine dependence, cigarettes, in remission. However, the facility’s social history and assessment recorded no history of nicotine/tobacco use and no current use of smoking products. The resident’s face sheet and diagnosis list initially reflected nicotine dependence, unspecified and uncomplicated, rather than nicotine dependence in remission, and at one point showed differing onset dates and diagnosis descriptions for nicotine dependence. The resident, who reported having stopped smoking months earlier and expressed concern that an active nicotine dependence diagnosis would affect acceptance into assisted living, identified the coding issue and requested correction. The MDS coordinator stated that diagnoses are typically entered from hospital records at admission and updated when aware of new information, but acknowledged not knowing about the resident’s additional hospital visit and CT results, and that the nicotine diagnosis had been entered as dependence instead of remission. The DON reported that the resident makes her own appointments and provides records to medical records staff, and that multiple outside physicians with differing diagnoses contributed to confusion. The former nurse practitioner stated that diagnoses should be carried over from the hospital stay and updated to manage new problems, but the nicotine-related diagnosis in the facility record was not accurately aligned with the resident’s remission status, resulting in an incomplete and inaccurate medical record.
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