Inaccurate Documentation of Resident Care
Penalty
Summary
The facility failed to ensure accurate documentation of resident care, specifically for a resident who was supposed to receive Range of Motion (ROM) exercises. The resident, who was cognitively intact and required assistance with activities of daily living, was ordered to receive daily ROM exercises after physical therapy was discontinued. However, the resident reported that these exercises had not been provided for several months, despite documentation indicating otherwise. Interviews with staff revealed inconsistencies in the provision and documentation of these exercises, with some staff unaware of the resident's care plan or mistakenly documenting that exercises were completed. The facility's policy required all services and changes in a resident's condition to be documented in the medical record. However, the Certified Nursing Assistants (CNAs) responsible for the resident's care did not perform the exercises and were unaware of the resident's current program. The Director of Nursing Service acknowledged the need for staff training on performing and documenting ROM exercises accurately. This deficiency highlights a failure in communication and adherence to care plans, resulting in inaccurate documentation of resident care.
Plan Of Correction
Plan of Correction: Approved February 28, 2025 1. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? - Resident # 66 was assessed by OT on (2/27/2025) and had no negative outcomes from the deficient practice. - Task in CNA Accountability (Point of Care) was revised to provide clear instructions pertinent to Range of Motion exercises on 2/27/2025. - Certified Nursing Assistant # 9 was re-educated on the following plan of care listed in electronic Kardex on 2/27/2025. - Certified Nursing Assistant # 11 was re-educated on the accuracy of documentation on 2/27/2025. 2. How you will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken? - All residents on restorative nursing care have the potential to be affected by this practice. - An audit is being conducted on all residents on the Restorative Nursing Care to ensure the tasks are documented accurately based on actual provision of care. 3. What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not recur? - The facility Policy and Procedure titled “Charting and Documentation” was reviewed, dated and no revision was required. - All interdisciplinary teams are being in-serviced on the above policy and procedure with an emphasis on the importance of documentation accuracy. - Thorough training on proper documentation practices was added to the orientation and thereafter annual education. - New process is being implemented to ensure compliance with documentation by interviewing 2-3 employees on a monthly basis regarding proper documentation policy and procedure. - The audit tool was created to ensure compliance. 4. How the corrective action(s) will be monitored to ensure the deficient practice will not recur? - On a weekly basis for the first quarter, the Director of Nursing, or designee, will randomly check and audit 3-5 residents’ medical records for accurate documentation of care provided. Any outstanding issues will be addressed immediately and reported to the Administrator. - On a monthly basis, the Director of Nursing will report the findings to the Administrator. - On a quarterly basis, the Director of Nursing will report the findings to the QAPI Committee. - QAPI Committee to determine if further action is required. 5. The title of the person responsible for correction of each deficiency: Director of Nursing & Asst. Dir of Nursing.