Inconsistent Nursing Documentation of Resident's Hearing Status
Summary
The facility failed to ensure that nurses' notes were meaningful, informative, and consistent for one resident. Specifically, the daily skilled charting notes documented the resident's hearing as adequate, while the weekly progress notes indicated the resident was hearing impaired and hard of hearing. This inconsistency in documentation was confirmed by the Director of Nursing during a review of the resident's records. The resident involved had a history of left hip replacement and required supplemental oxygen. The facility's policy required accurate and thorough assessment of residents' health status, but a policy specifically addressing the accuracy of medical records was requested and not provided. The inconsistent documentation of the resident's hearing status had the potential for the resident's specific care needs to go unmet.
Penalty
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