Deficiency in Documentation of Resident Care
Penalty
Summary
The facility failed to maintain accurate and complete medical records for three residents, leading to deficiencies in documentation of care provided. For one resident, the facility did not document incontinence care as required. The resident had a care plan that included a toileting schedule, but the task log showed inconsistencies and missing entries for when care was performed. Interviews with staff revealed that documentation was not always completed in a timely manner, and there was confusion about where and how to document the care provided. Two other residents also experienced issues with documentation. Certified Nurse Aides did not consistently document the amount of meals consumed, consumption of supplements, and nourishment for bedtime snacks. The care plans for these residents included specific dietary interventions, but the Point of Care Response History showed incomplete or missing documentation for several dates. Interviews with nursing staff indicated that there was an expectation for documentation to be completed, but it was not consistently checked or verified. The lack of proper documentation was acknowledged by the facility's Assistant Director of Nursing, who noted that there was a documentation issue. The failure to accurately document care provided to residents, including toileting and nutritional intake, was a significant deficiency that was identified during the recertification survey. This deficiency highlights the need for improved processes and oversight to ensure that all care provided is accurately recorded in accordance with professional standards.
Plan Of Correction
Plan of Correction: Approved January 16, 2025 1. Residents #21, #144, and #171 documentation will be reviewed by the Registered Nurse Manager, with a summary assessment documented on their toileting or nutritional intake (based on nature of identified missing documentation). Missed documentation of this type cannot be accurately recreated in a retrospective manner, and a summary of the resident's status based on the Registered Nurse assessment is appropriate to substitute in this manner. 2. All residents on a specific toileting program or identified as high risk nutritionally requiring meal intake monitoring will be reviewed to assure their plan is appropriate and the documentation is substantially complete. If found to be insufficient, a summary assessment will be conducted and documented on their toileting or nutritional status by the Registered Nurse. See further explanation under #1 above. 3. The following corrective measures will be implemented: a. Toileting documentation – Certified Nursing Assistants will receive remediation on the purpose, importance and policy requirements of clinical task documentation. Within the last hour of each scheduled shift, the Licensed Practical Nurse (charge nurse) will review all task documentation that is outstanding via electronic reporting and communicate findings to assigned CNAs. Information will be provided to Registered Nurse Manager, who will provide ongoing counseling and education as necessary on the units. b. Intake Recording – Certified Nursing Assistants will receive remediation on the purpose, importance and policy requirements for intake monitoring and documentation. Hand-held devices (tablets) will be deployed in the dining areas for documentation at each meal. Charge Nurse will maintain a list of residents on intake monitoring, validating documentation completeness and accuracy during and after each meal. No documentation policy changes were indicated. In the event the charge nurse is unable to perform the audits at the end of their shift, they will first do a verbal check in with the aides; and second, if necessary, will report to their Nurse Manager or Supervisor they were unable to complete this task. 4. Registered Nurse Unit Managers will audit (visually review of documentation in electronic health record) compliance for no less than 4 days per week (using a 24 hour report) for 3 months, and 2 days per week for 3 months to determine compliance, with results reported monthly to Quality Assurance & Performance Improvement. In the event any particular unit(s) find continuing compliance issues, the findings will be reviewed with the Director of Nursing (or designee) to determine if increasing frequency of review is indicated (vs. isolated performance issue). Frequency of audits will be reevaluated after 6 months by Quality Assurance & Performance Improvement committee. Frequency of auditing may be increased at any point by the quality assurance and performance improvement committee based on audit results. Responsible Party: Assistant Director of Nursing for Quality and Education