Incomplete Documentation of Treatment Administration
Penalty
Summary
Edenbrook of Yeadon was found to be non-compliant with federal and state regulations regarding the maintenance and confidentiality of resident records. Specifically, the facility failed to ensure complete and accurate treatment administration for a resident identified as CL1. This resident was admitted with a cognitive communication deficit and a chest surgical incision following an aortic valve replacement and coronary artery bypass surgery. The physician's orders required specific incision care, including washing with mild soap and avoiding lotions or immersion in water, to be performed every day and evening for four weeks. The deficiency was identified through a review of the treatment administration record, which showed that incision care was documented as completed from January 23 to January 31, 2025. However, the records for February 1 and February 2, 2025, were left blank. An interview with the Director of Nursing and the Administrator revealed that the facility had transitioned to paper documentation during this period due to a switch to an Electronic Administration Record system. This transition resulted in incomplete documentation of the required treatment for Resident CL1.
Plan Of Correction
The facility is unable to retroactively correct. Current facility residents ETAR documentation for the last 2 weeks will be reviewed to determine if the deficient practice affected other residents. Identified residents will be assessed by RN staff where needed, along with the completion of a treatment error report. NHA, DON and/or Designee will conduct weekly audits for 4 weeks to ensure documentation protocol is complete, then monthly for 3 months to ensure compliance. Results of monthly audits will be reported to the QA Steering committee by the NHA/DON and/or Designee for 3 months to the QA Steering committee for action. Following the 3 months, the committee will determine the frequency and need of additional audits moving forward.