Deficiency in Medical Record Documentation
Penalty
Summary
The facility failed to maintain accurately documented and complete medical records for a resident, as evidenced by the absence of documentation for psychological assessment attempts and missing weight records. The resident, who was not present at the facility during the survey, had been admitted with diagnoses including spinal stenosis, atherosclerotic heart disease, and type 2 diabetes. The Admission Minimum Data Set (MDS) indicated an intact cognition and moderate depression. However, the psychologist's attempts to assess the resident were not documented, despite the psychologist stating that she had tried to see the resident multiple times but found him sleeping. Additionally, the facility did not document the resident's weekly weights for two consecutive weeks following admission, as required by the facility's policy. The Registered Dietician confirmed the missing weights and stated that new admissions should be weighed weekly for four weeks. The facility's policies on weight assessment and documentation were reviewed, revealing that all services and changes in the resident's condition should be documented to facilitate communication among the interdisciplinary team. The lack of documentation for both the psychological assessment attempts and the resident's weights led to the identification of this deficiency.
Plan Of Correction
1/24/25 1) How the corrective action will be accomplished for those residents found to have been affected by the deficient practice. Resident #1 [R] NJ Ex Order 26.4(b) (1) at the facility. The Assistant Director of Nursing/Facility Educator (ADON/FE) immediately conducted an audit of all residents with referrals for J Ex Order 26.4(b)(1) assessment to ensure the assessment was completed timely. There were no untoward findings. The Dietician conducted an audit of all residents residing in the facility to ensure NJ Ex Order 26.4(b) (1) were obtained and entered in the electronic medical record for all new admissions. No residents had untoward effects related to this practice. 2) How the facility will identify other residents having the potential to be affected by the same deficient practice. All residents have the potential to be affected by this practice. 3) What measures will be put into place or systemic changes will be made to ensure that the deficient practice will not recur. On 12/27/2024, The Assistant Director of Nursing/Facility Educator (ADON/FE) provided in-service education to all nurses on the importance of ensuring the contracted vendor for psychology services documented attempts for psychological assessments on residents. On 12/27/2024, The Assistant Director of Nursing/Facility Educator (ADON/FE) provided in-service education to all nurses, Certified Nursing Assistants (CNAs), and the U.S. FOIA (6) (6) on the procedure for documenting weights for new admissions. Weights will be obtained for all new admissions, on the date of admission to the facility. The Dietician or designee will review the admission weight the day after admission, to ensure it is documented in the electronic medical record. 4) How the facility will monitor its corrective actions to ensure that the deficient practice is being corrected and will not recur, i.e. what QA program will be put into place to monitor the continued effectiveness of the systemic change. The Unit Manager or designee will conduct audits of residents with psychology/psychiatry referrals to ensure the provider documents attempts to complete the psychological assessment. The audits will be conducted on 5 residents per week x 3 weeks, then 5 residents per month x 3 months, then 5 residents per quarter x 3 quarters to ensure compliance. The dietitian or designee will conduct audits of residents' admission weights to ensure proper completion. These results will be monitored weekly. The results of the audits will be provided monthly x 3 months, then quarterly x 3 quarters to the facility's Administrator and the Quality Assurance Performance Improvement (QAPI) Committee. The QAPI committee meets on a monthly basis. The QAPI Committee will review and determine the need for further audits.