Incomplete Change of Condition Documentation for Resident Receiving Bisacodyl Suppository
Penalty
Summary
The deficiency involves the facility’s failure to maintain an accurate and complete medical record for one of three sampled residents by not fully completing a Change of Condition (COC) document. The resident was admitted with diagnoses including sequelae of nontraumatic intracerebral hemorrhage, diabetes mellitus, and generalized weakness. A History and Physical dated shortly after admission documented that the resident was alert and oriented to person, place, and time. A subsequent Minimum Data Set indicated the resident’s cognitive skills for daily decision-making were intact and that the resident required maximum assistance for all ADLs. On the date of the documented change in condition, the COC form recorded that a bisacodyl suppository was inserted into the resident’s frontal private area, and the section for the date of the last bowel movement was left blank. A family member reported that a suppository had been inserted in the wrong area. During interview and concurrent record review, an LVN confirmed that the COC did not include the date of the last bowel movement to justify the use of bisacodyl and stated the importance of accurate medical records to ensure appropriate treatment. The DON stated that the responsible LVN should have completed the COC to ensure a complete and accurate medical record. The facility’s documentation policy and SBAR Charting Form instructions require that relevant findings be documented in the clinical record and that all sections of the form be completed, or marked N/A if not applicable.
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