Deficiency in Accurate Medical Record Documentation
Penalty
Summary
The facility failed to maintain accurate and complete clinical records for two residents, leading to a deficiency in compliance with federal and state regulations. Resident 2, diagnosed with muscle wasting and anemia, had physician's orders to cleanse the sacrum with medihoney and apply skin prep to both heels. However, the treatment administration record (TAR) for February 2025 lacked documentation of these treatments on specific dates, despite the resident confirming that the treatments were applied as ordered. Similarly, Resident 3, also diagnosed with muscle wasting and anemia, had orders to apply skin prep to both heels and a blister on the abdomen. The TAR for February 2025 showed missing documentation for these treatments on several dates, even though the resident confirmed the treatments were administered. The Director of Nursing acknowledged the failure to properly document the treatments, confirming the deficiency in maintaining complete and accurate medical records.
Plan Of Correction
This Plan of Correction constitutes this facility's written allegation of compliance for the deficiencies cited. This submission of this plan of correction is not an admission of or agreement with the deficiencies or conclusions contained in the Department's inspection report. 1. Resident 2 and 3 Treatments were provided as ordered. 2. An initial audit was completed for residents receiving skin prep to validate residents treatments were documented as administered. Variances were addressed at the time of the audit and placed on the facility audit tool. 3. Licensed nursing staff were educated on the documentation process for treatments. 4. DON/ designee will complete audits 3x per week x4 weeks to validate residents treatments were documented as administered. Audit findings will be addressed and submitted to the Quality Assurance Performance Improvement Committee for further review and recommendations as needed.