Incomplete Documentation of Resident's Medical Records
Penalty
Summary
The facility failed to ensure that Resident 5's medical records were complete and accurately documented. Resident 5 had diagnoses including a fracture of the left ulna and an anxiety disorder. A review of the resident's January Treatment Administration Record (TAR) revealed that the order for the resident to wear a splint three times a day and ensure the left arm splint was on at all times was not documented as completed on several dates across different shifts in January and February 2025. During an interview with Resident 5, it was revealed that she wore the brace at all times since her cast was removed approximately two weeks prior. Despite this, the facility had no additional information to provide regarding the missing documentation, as confirmed in an email correspondence with the Nursing Home Administrator. The NHA stated that it was the facility's expectation for documentation to be completed accurately.
Plan Of Correction
1. Resident 5 evaluated for any negative outcome related to missing documentation of splints. No negative outcomes have been identified. Licensed staff will be educated on TAR documentation requirements for all Residents with orders for splints or braces. 2. Residents with splints or braces will be audited to review documentation and orders for the last 14 days. 3. DON or designee will complete audits for documentation for Residents with a splint or brace present in the TAR. Audits will continue weekly for 4 weeks, monthly for 2 months. 4. Audits and findings will be submitted in the Quarterly QAPI committee meetings.