Failure to Document Resident Altercations
Penalty
Summary
The facility failed to maintain complete and accurate medical records for one of the residents reviewed, specifically regarding the documentation of abusive behaviors. On February 26, 2025, Resident #105 was involved in two separate incidents where they aggressively confronted another resident, Resident #106, in the hallway and later in the therapy gym. Despite witnessing these altercations, LPN H did not document the incidents in Resident #105's medical records. LPN H reported the incident to the Nursing Home Administrator (NHA) the following day but was instructed not to document it due to concerns about the impact on Resident #105's transfer referrals. The lack of documentation meant that the Physician's Assistant (PA) responsible for managing Resident #105's behaviors was unaware of the incidents and could not evaluate or adjust interventions accordingly. The Director of Nursing (DON) confirmed that staff are expected to report and document any potential abuse immediately, but this protocol was not followed. The failure to document these incidents resulted in a lack of proper evaluation and monitoring of Resident #105's behaviors, potentially compromising the safety and well-being of other residents.
Plan Of Correction
Element 1: Resident #105 no longer resides at the facility. Resident #106 care plan was reviewed and updated as needed, well-being visits completed with resident and reflected no lasting negative outcomes from the incident. Element 2: All residents have the potential to be affected by this practice. IDT team reviewed 24-hour on 3/19/2025 to review all residents and ensure information was not missing from medical record. Element 3: Clinical staff have been re-educated by the DON/designee on Nursing documentation of healthcare data from Perry and Potter 10th edition pg 51- 53; Legal guidelines for documenting and reporting and recording. to include timely documentation of resident condition variances. Those not receiving the education prior to date of allegation of compliance 3/24/25 will complete the education prior to their next scheduled shift. Element 4: Facility IDT will review the electronic health record during facility daily clinical meeting Monday through Friday with a lookback review done on Monday for any weekend documentation. The DON/designee will follow up on any identified missing or incomplete documentation. Any incomplete documentation will be resolved upon identification. Results will be reported to QAPI, and audits will not be discontinued until substantial compliance is achieved. The Administrator is responsible for achieving and sustaining compliance.