Inaccurate Documentation of Restorative Nursing Services
Penalty
Summary
The facility failed to ensure accurate documentation of restorative nursing services (RNS) provided to a resident, as required by federal regulations and the facility's own policy. Specifically, restorative nursing assistants (RNAs) initialed the Restorative Nursing Flow Sheet (RNFS) to indicate that range of motion (ROM) exercises were provided to the resident on multiple dates, even though they were not present or did not perform the ordered interventions. Review of timecards and staffing sign-in sheets confirmed that on several dates, the RNAs who initialed the RNFS were not working, and the Director of Staff Development (DSD) could not verify whether the resident received the required RNS on those days. Further investigation revealed that on some occasions, an RNA documented that the full treatment was completed when, in fact, only a partial treatment or no treatment was provided. The RNA admitted to initialing the RNFS to indicate completion of the ordered exercises even when unable to perform them, citing lack of time as a reason. The resident also reported that RNAs sometimes did not provide the RNS as ordered or only completed part of the treatment. This resulted in the resident's medical record containing inaccurate information regarding the care and services provided. The facility's policy on charting and documentation requires that all services provided, progress toward care plan goals, and any changes in the resident's condition be objectively, completely, and accurately documented in the medical record. Interviews with nursing staff confirmed that documenting care as completed when it was not is considered willful falsification of medical records. The inaccurate documentation and failure to provide ordered RNS could not be verified or corrected due to the lack of accurate records, directly impacting the integrity of the resident's medical record.
Plan Of Correction
How corrective actions will be accomplished for those residents found to have been affected by the deficient practice: On February 27, 2025, licensed nursing staff and Rehab assessed Resident 2 for any adverse effects associated with missed restorative nursing assistant (RNA) orders. No ill effects were observed, and there was no decline in range of motion. RNA 1 and RNA 2 are no longer employed in the facility. Additionally, on March 5, 2025, the Administrator or designee held a one-on-one in-service session with RNA 5 along with a counseling, focusing on the importance of following RNA orders for Resident 2 and other residents in the program. This training emphasized essential steps for enhancing compliance and ensuring that residents' needs are effectively met. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All residents have the potential to be affected by this deficient practice. On March 18th, 2025, the Director of Nursing (DON) or designee reviewed residents participating in the restorative nursing assistant (RNA) program to confirm that treatments were properly authenticated and administered, thereby preventing any further decline in range of motion (ROM). No additional concerns were identified. What measures will be put into place or what systemic changes will the facility make to ensure that the deficient practice does not recur: The facility's Director of Staff Development (DSD) resigned on March 7, 2025. A new DSD is scheduled to be onboarded on March 19, 2025, and appropriate policies and procedures will be followed to ensure the timely and accurate completion of Restorative Nursing flow sheets. On March 20th, 2025, facility restorative nursing assistants (RNAs) participated in an in-service training conducted by the Administrator or designee. This training emphasized the importance of adhering to RNA orders for residents and the necessity of accurate charting related to RNA treatments. The Director of Nursing (DON)/designee will review RNA treatments on a weekly basis to ensure that orders are being properly implemented and documented. The DSD/designee will conduct random rounds during RNA treatments to verify that orders are being executed as specified. Any negative findings will be reported to the Administrator for further review. How the facility plans to monitor its performance to make sure that solutions are sustained: The Admin/designee will provide any negative findings to the QAPI committee monthly for three months for further monitoring and action planning as indicated or until the QAA committee determines compliance. Date of Compliance: March 20th, 2025.