Failure to Document Assessment and CPR Prior to Resident Death
Penalty
Summary
The deficiency involves the facility’s failure to maintain a complete and accurate medical record for one hospice resident who was a full code. The resident had COPD, a left ischium fracture, and hypertension, and required maximum assistance for eating and was dependent for toileting and hygiene. After a prior change in condition related to oxygenation and a hospital transfer, the resident was readmitted with hospice services, remained full code, and expressed a desire for comfort measures without further hospitalizations. Nursing notes documented the resident’s gradual decline, refusal of food and medications, and the resident’s wish to avoid further hospitalizations, but the only entry related to the resident’s death was a nurse’s note stating the time of death per hospice at 6:40 p.m., with no documentation of any assessment or actions that preceded the death. Interviews revealed that when the resident was found unresponsive, the Interim DON assessed the resident as having no pulse and no respirations, released the air mattress, and began CPR while directing staff to obtain the crash cart. The ADON returned from lunch, assisted with CPR and application of the AED, and paramedics who were already in the building came to assist and pronounced the resident dead, after which hospice was notified and the hospice nurse officially pronounced death. The ADON did not document any assessment or CPR in the medical record, and the Interim DON documented the assessment and interventions on a facility risk management form instead of in the resident’s medical record. As a result, the resident’s medical record lacked documentation of the assessment and resuscitative efforts that occurred prior to the recorded time of death.
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