Failure to Maintain Complete Clinical Record for Resident Death Event
Penalty
Summary
The deficiency involves the facility’s failure to maintain a complete and accurate clinical record for a resident who experienced a change in condition and subsequent death. Facility policy required that when a change in condition is identified, the RN assess the resident, notify the physician, and document all assessment findings, evaluations, interventions, changes in orders, and, if the resident expires, a physical assessment confirming absence of pulse and respirations, pronouncement details, notifications, code status, and post-mortem care. The resident had intact cognition and diagnoses including hypertensive heart disease with heart failure, COPD, and coronary artery disease, and had documented do not intubate and do not resuscitate orders. On the date of death, a social service note and the death certificate documented that the resident passed that morning, and that the next of kin and funeral home were notified. However, review of the resident’s medical record showed no nursing documentation of the death event, including the time the resident was found unresponsive, assessment of the change in condition, confirmation of DNR status, time of death, physician notification, or body release details. Interviews revealed that the resident’s roommate alerted staff that the resident was not feeling well, that the resident was uneasy, gasping, and holding their chest, and that staff assessed vital signs, applied oxygen via non-rebreather mask, attempted IV access, and confirmed DNR status using the wristband and medical orders. The DON and nursing supervisors were present, and the DON pronounced the death, contacted the family, and reported documenting in the electronic record, but there was no corresponding nursing progress note in the resident’s chart. Both the LPN and RN supervisor acknowledged that required progress notes regarding the change in condition and death were not entered, and could not explain the lack of documentation, resulting in an incomplete clinical record not maintained in accordance with accepted professional standards and practices.
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