Need help please! Scenario: LTC resident goes to hospital for malnutrition,
dehydration. Receives peg tube then returns to facility as SNF with dx of
dehydration. Nurses documenting "Y" for s/s of dehydration (which are listed out on
medication sheets). On 5 day assessment, Coded 276.5 (dehydration) on section I
secondary to dx of dehydration on admission orders and documented s/s of dehydration
during observation period. On 14 day, continued documentation by nurses of s/s of
dehydration so I left 276.5 on the 14 day assessment as well (sentinel event). DON
states modification needs to be done and transmitted to state to take dehydration off
the 14 day assessment as it should not have been carried over to that assessment
anyway and nurses have written over the "Y"'s they documented with "N' for no s/s of
dehydration. DON states they meant they were monitoring for s/s of dehydration, not
that she had s/s of it. (but they made that mistake on only one patient?) Should I
not have left the 276.5 (dehydration) on the 14 day when the patient had a written dx
and documented s/s of dehydration? What would you all do? And, won't it look strange
to a surveyor who looks at the original 14 day assessment and the modified 14 day
assessment (original one with dehydration and the corrected one without as well as the
nurses documentation of "Y" for s/s of dehydration noted written over with "N" for no
s/s of dehydration noted. I don't know what to
do?........................................
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