Failure to Document Vital Signs During Change of Condition
Penalty
Summary
The facility failed to maintain complete and accurate medical records for one resident by not documenting vital signs during a change of condition. The resident was admitted with metabolic encephalopathy, cerebral infarction, and unspecified dementia, and had severely impaired cognitive skills for daily decision making per the MDS dated 2/14/2026. On 2/26/2026 at 10:30 a.m., a Change of Condition (COC) Assessment Form documented that the resident was confused, unable to make eye contact, and staring to the right side, with vital sign values recorded in the Background section of the form. Later, at 12 p.m., the resident was observed with increased weakness on the left side of the body and facial twitching, and the COC Assessment Form stated that the resident’s vital signs were within normal range, but no actual vital sign values were documented to support this. During a telephone interview, RN 1 stated that licensed nurses were monitoring the resident every 15 minutes, including vital signs, but acknowledged that she did not document this monitoring in the resident’s medical record and that she should have documented the resident’s COC progress or decline. In a subsequent interview and concurrent record review with the DON, the DON confirmed there was no documented evidence of the resident’s vital signs after the second COC at 12 p.m. on 2/26/2026 and stated that failure to document vital signs after a COC could result in miscommunication among the healthcare team. The facility’s Charting and Documentation policy, last reviewed on 4/16/2025, required that all services provided and any changes in the resident’s condition be documented in an objective, complete, and accurate manner, which was not followed in this case.
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