Failure to Document Resident Smoking Incidents
Penalty
Summary
The facility failed to maintain complete and accurate clinical records for a resident, identified as Resident R24, as required by professional standards. On multiple occasions, staff detected a smoking odor in Resident R24's room, and evidence of smoking, such as cigarette burn holes and a burnt-out cigarette, was observed. Despite these observations, the incidents were not documented in the resident's clinical records. The Social Worker, Employee E13, revealed that the Administrator advised against documenting these instances to avoid creating a record of non-compliance, which could complicate finding alternative placements for the resident. Additionally, a morning meeting was held on January 3, 2025, where the administrative team discussed concerns about Resident R24's smoking behavior. However, no documentation of this meeting or the discussion was recorded. The Director of Nursing confirmed the occurrence of this meeting and acknowledged that there were additional incidents involving Resident R24 that were not documented. This lack of documentation violates the requirements for maintaining clinical records and nursing services as per the relevant Pennsylvania Code.
Plan Of Correction
1. The administrator responsible no longer works for the facility as of September 2024. Staff were educated on the importance of proper documentation. 2. Audit of the current residents for the last 30 days will be done to ensure proper documentation; any concerns will be corrected immediately. 3. Staff will be educated on the components of this regulation with an emphasis on maintaining resident records with identifiable information securely and accurately. 4. Five residents' notes were audited for proper documentation once a week for one month, twice a month for one month, and then once a month for one month. 5. The findings of these quality monitoring activities will be reported to the Quality Assurance/Performance Improvement Committee monthly for six months.