Failure to Document Resident Incident and Care
Penalty
Summary
The facility failed to ensure accurate and complete documentation for a 98-year-old male resident with multiple diagnoses, including dementia and impaired mobility. The resident was admitted to the facility and required assistance with transfers and toileting due to his cognitive and physical impairments. An incident occurred where the resident was found wandering without his walker and ended up in another resident's bathroom. Despite the family reporting this incident and increasing private sitter care to 24/7, there was no documentation of the incident in the resident's clinical records or the facility's incident log. Interviews with facility staff, including the Administrator and the Director of Nursing (DON), revealed that the incident was known but not documented. The Administrator acknowledged the incident and stated it was reported to the night shift nurse, but no record of this was found. The DON confirmed that no documentation could be identified regarding the incident or any subsequent assessments or monitoring of the resident's condition. The facility's policy requires timely and accurate documentation of residents' experiences, which was not adhered to in this case.
Plan Of Correction
Resident #55 was seen by the nurse practitioner on and and into no adverse effects of another resident room were noted. An audit was conducted with staff nursing on each shift to determine if any unusual occurrences or behaviors have occurred and verified if documentation has occurred. Licensed nurses were provided education by regarding documentation of resident experience to include any unusual occurrences or incidents that have occurred on the shift. If there is an unusual occurrence, staff should assess the patient and implement appropriate interventions if necessary. DON and/or designee will complete 4 random interviews with staff on each shift weekly for 3 months to determine if any unusual occurrences or behaviors have been observed, and then DON and/or designee will audit resident records to ensure this has been appropriately reflected in the resident record. The results of the audits will be submitted to the Administrator for review and discussed at the monthly QAPI committee meeting. The committee will direct improvement to the plan when necessary to achieve and maintain compliance.