Documentation Failures in Resident Care
Penalty
Summary
The facility failed to maintain complete and accurate documentation for two residents, leading to deficiencies in care. For Resident R1, who has a tracheostomy, gastrostomy tube, and spastic quadriplegic cerebral palsy, the clinical records showed discrepancies in the documentation of enteral feeding and water flushes. The records indicated that Resident R1 received less than the ordered amount of water flushes and formula on multiple occasions, and there were instances where no documentation was available for the water flushes and formula intake. The Director of Nursing confirmed the inaccuracies in Resident R1's clinical record regarding the tube feeding formula and water flushes. For Resident R37, who has diabetes, high blood pressure, and a urinary tract infection (UTI), the clinical records inaccurately documented the administration of Keflex, an antibiotic prescribed for the UTI. Although the last dose was administered on 12/21/24, progress notes continued to indicate that Resident R37 was receiving Keflex for several days afterward. The Director of Nursing confirmed the inaccuracies in Resident R37's clinical record related to the administration of Keflex. These documentation failures were identified during a review of facility policy, clinical records, and staff interviews.
Plan Of Correction
Facility has reviewed all other residents and determined no others were affected. Education has been provided on policy for enteral feeds and flushes with all licensed nursing staff to ensure care plans and physician orders are being followed and recorded accurately. Documentation of med administration policy has been educated and reviewed with all nursing staff. Director of Nursing or designee will audit 5 charts for errors in antibiotics as well as flushes and feeds being documented appropriately daily for 2 weeks and 3 times weekly for 6 weeks. R1 care-plan was reviewed along with current status; it was determined R1 did not receive any adverse effects. Residents' weight is maintained with no evidence of dehydration. R37 also did not have adverse effects because the antibiotic was completed in the 7 day course. Facility has identified this as a performance improvement program for their Quality Assurance Performance Improvement (QAPI) Program. We will review quarterly with QAPI and track progress.