Incomplete Documentation and Assessment of Resident's Care
Penalty
Summary
The facility failed to ensure that a resident's clinical records were complete and accurately documented. A quarterly Minimum Data Set (MDS) assessment for a resident revealed cognitive impairment and dependency on staff for all daily care needs. An incident occurred where the resident was yelling and resisting care, and a nurse aide was observed forcing the resident's arm in a manner that resulted in a deformity and complaints of pain. Despite the resident's complaints, there was no documented evidence of a comprehensive assessment by a registered nurse on the days following the incident. Interviews with staff, including a registered nurse and the Director of Nursing, confirmed the lack of documentation regarding the resident's assessment on the specified dates. The registered nurse admitted to only assessing the resident from the elbow down due to resistance, and the Director of Nursing acknowledged the absence of necessary documentation in the resident's clinical record. This lack of documentation and incomplete assessment contributed to the deficiency identified in the facility's handling of the resident's care.
Plan Of Correction
1. Documentation of the registered nurse pain assessment that was completed on 11/15/2024 was submitted as part of an investigation witness statement on 11/19/2024 by the assessing nurse. This document is filed in the resident's paper chart. 2. Individual counseling occurred with RN who completed the pain assessment and failed to document in electronic medical record on 11/27/2024. Oral discipline was issued due to failure to follow FCMC Pain Assessment and Management policy that states pain assessments must be documented in electronic medical record. 3. All Registered Nurse staff educated to the FCMC Pain Assessment and Management policy including documentation in electronic medical record and reporting new pain to the Inter Disciplinary Team at the morning clinical meeting. 4. Monitoring of documentation of pain assessments with reports of new pain will be completed on change in condition tracker at daily morning clinical meeting. Director of nursing will follow up individually with staff with appropriate discipline when documentation is not complete.