Failure to Document Provider Communication During Resident’s Change in Condition
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete medical records and document provider communication during a resident’s change in condition, as required by its Change in Condition of the Resident policy. That policy specifies that documentation must include a description of the change, assessment findings, emergency care provided, provider notification with date, time, conveyed information, and orders received, responsible party notification, and names and titles of employees involved. The resident at issue had vascular dementia, a history of UTI, obstructive and reflux uropathy, benign prostatic hypertrophy with lower urinary tract symptoms, and an indwelling urinary catheter. The resident’s care plan directed staff to report changes in urine amount, color, or odor, and to report signs of UTI such as blood, cloudy urine, fever, increased restlessness, lethargy, or pain/burning to the physician. On the date in question, a nursing progress note recorded that the resident was in the hall with a walker, believed it was time for breakfast, was reoriented and assisted back to bed, and that the indwelling catheter was draining milky, yellow urine. Later that day, an eINTERACT SBAR note documented abnormal blood pressure and increased confusion, and that the provider ordered a urinalysis/culture and increased oral fluids. A physician discharge summary indicated the medical director and family were aware of orders to send the resident to urgent care, from which the resident was admitted to the hospital. The DON reported she was notified of the resident’s condition early that morning, called the urology department to seek an appointment, and later received instructions to send the resident to urgent care, but acknowledged she did not document in a progress note that she notified the physician or the urology department, despite the policy requirement. The ED also stated the resident’s change in condition should have been documented earlier in the day, demonstrating incomplete documentation of the change in condition and related provider communication.
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