Inaccurate Documentation of Resident Assessment
Penalty
Summary
The facility failed to accurately document in the clinical record for one resident, identified as Resident #60, during a time when the resident was not present in the facility. An observation noted that Resident #60 was sitting up in bed with a meal and did not appear to be in visible distress. However, a review of the Skilled Nursing Facility/Nursing Facility to Hospital Transfer form indicated that the resident had been transferred to an acute care facility for a procedure. Despite this, a Daily Medicare A/Managed Care Nursing Note was documented, detailing a physical assessment of the resident, which included various health metrics and observations, even though the resident was not in the facility at the time. Interviews with facility staff, including a Licensed Practical Nurse (LPN) and the Assistant Director of Nursing (ADON), revealed inconsistencies in the documentation process. The LPN acknowledged that a mistake might have been made, as it was not typical to document on a discharged resident. The ADON confirmed that the resident had been discharged and should not have been documented on, except for a hospital follow-up note. The ADON also noted that the expectation was to assess and document accurately, indicating that the note in question was incorrect. The facility's policy on clinical documentation emphasized the need for accurate and timely entries that reflect the care and services provided to residents. The policy outlined the importance of maintaining a complete account of the resident's care, treatment, and response, as well as supporting quality medical care and legal records. However, the documentation for Resident #60 did not adhere to these standards, as it included an assessment for a resident who was not present in the facility, highlighting a lapse in the facility's documentation practices.
Plan Of Correction
The Director of Nursing (DON) interviewed the nurse who entered the incorrect documentation into the medical record for Resident #60 on [date], and then followed the facility policy for incorrect documentation and struck out the incorrect documentation for Resident #60 on [date]. On [date], the Director of Nursing/designee initiated an audit on other residents discharged from [date] to [date] and there were no other residents that had documentation after discharge. On [date], the Director of Nursing provided education to the facility per diem nurse that incorrectly documented on discharged resident #60. On [date], the Director of Nursing/designee initiated education for the other nurses related to accurate and complete resident documentation on current residents only. The education was completed by [date]. The Director of Nursing/designee will complete an audit a minimum of one time per week for 12 weeks. This weekly audit will be to review discharged residents for the week to ensure that there is no incorrect documentation entered after a resident has discharged. The Director of Nursing/designee will review the audits with the monthly Quality Assurance Performance Improvement (QAPI) Committee for three months. The Quality Assurance Performance Improvement committee will evaluate the outcome of the audits and if necessary, amend the improvement plan and continue to monitor until substantial compliance has been determined by the committee.