Inaccurate IDT Documentation of Restraint Use and Clinical Status
Penalty
Summary
The facility failed to ensure that Interdisciplinary Team (IDT) notes accurately reflected a resident’s current status, resulting in discrepancies in the medical record. The resident was initially admitted with chronic respiratory failure with hypoxia, a tracheostomy, and ventilator dependence, and was later discharged to a general acute care hospital. Review of the IDT Monthly Meeting Notes for multiple months showed documentation of restraints described as two bedrails raised and locked while in bed for seizure activity and whole body jerking while coughing or while being suctioned. However, there was no documented evidence in the medical record that the resident had a diagnosis of seizures from admission through discharge. During an interview and concurrent record review with the Director of Subacute and the Nurse Manager, it was confirmed that the medical record did not contain a seizure diagnosis for the resident, despite the repeated references to seizure activity in the IDT Monthly Meeting Notes. The Director of Subacute stated that the IDT notes inaccurately reflected the resident’s restraint usage by citing a seizure diagnosis instead of documenting the use of two locked bedrails for ventilator-dependent whole body jerking while coughing or during suctioning. The Director further stated that the MDS nurse failed to adequately customize the IDT Monthly Meeting Notes to reflect the resident’s correct clinical status, resulting in documentation that did not accurately represent the resident’s specific condition, contrary to the facility’s policy requiring accurate completion of medical records for patient safety.
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