Incomplete Documentation of Resident Assessments
Penalty
Summary
Westminster Woods at Huntingdon was found to be non-compliant with federal and state regulations regarding the maintenance and documentation of resident medical records. The facility failed to ensure that clinical records were complete and accurately documented for a resident who was cognitively impaired and had a history of stroke. On January 18, 2025, the resident was found on the floor, and although neurological checks were ordered, there was no documented evidence of registered nurse assessments at critical times when the resident's condition changed, such as when the resident complained of a dry mouth, had issues answering questions, and could no longer raise her arm. The facility's policy required documentation of all assessments and interventions following an incident, but this was not adhered to in the case of the resident. The Director of Nursing confirmed that the assessments were completed but not documented in the clinical record, which was a requirement. This lack of documentation was a violation of both federal regulations under 42 CFR Part 483 and state regulations under 28 PA Code, which mandate that medical records be complete, accurately documented, and systematically organized.
Plan Of Correction
Resident 1 Electronic Medical Record was updated to reflect nurse assessments in the clinical record. A review of current residents reported change in conditions that occurred in the last 30 days will be completed to ensure there is a documented nurse assessment in the clinical record. Education provided by Director of Nursing to current licensed staff the process to record nurse assessment in medical record after evaluation. Director of Nursing or designee will audit 3 random resident records for change in condition x 4wks, then 3 random records monthly for documentation of nursing assessment when appropriate. These audits will be forwarded to Quality Assurance for review.