Failure to Document Resident Interactions and Behaviors
Penalty
Summary
The facility failed to maintain accurate and complete clinical records for two residents, Resident 8 and Resident 44, as required by professional standards of practice. Resident 8, who was admitted with hypertensive heart disease, was cognitively intact according to a recent assessment. Resident 44, admitted with multiple sclerosis, was severely cognitively impaired. An incident occurred where Resident 44 kissed Resident 8 in the hallway, which was observed by staff. Despite the incident, there was no documentation in Resident 8's clinical record regarding the interaction, staff intervention, or any follow-up assessments to determine potential emotional or psychological effects. Similarly, Resident 44's clinical record lacked documentation of the behavior, assessments following the event, or any interventions to prevent recurrence. This lack of documentation resulted in incomplete and inaccurate clinical records for both residents. The Nursing Home Administrator and Director of Nursing confirmed that the nursing staff failed to consistently and accurately document residents' interactions and behaviors in the clinical records. This failure to document significant events and follow-up actions is a deficiency in maintaining accurate and complete clinical records, as required by the regulations.
Plan Of Correction
Medical records were updated on resident 8 and resident 44 to include investigation summary and outcome. Last 3 PB22's will be reviewed to ensure the presence of documentation in the medical record. Nursing staff will be re-educated on maintaining accurate and complete clinical records related to PB 22's. Audits will be completed on new PB22's to verify accurate and complete documentation weekly x 4 weeks, then monthly x 2 months. Findings will be reviewed at monthly QAPI meeting.