Failure to Document Use of Peek-a-Boo Mitten in Resident's Medical Record
Penalty
Summary
The facility failed to maintain accurate and systematically organized documentation in accordance with accepted professional standards for one resident who was using a peek-a-boo mitten to prevent removal of a gastrostomy tube. The resident, who had diagnoses including obstructive hydrocephalus, benign neoplasm of the spinal cord, other specified brain disorders, dysphagia, and was receiving care for a gastrostomy, had severe cognitive impairment as indicated by a BIMS score of 0. An order for the use of a peek-a-boo hand mitten was present in the resident's clinical record since admission. Despite the ongoing use of the mitten, the resident's weekly summaries did not document its use or any related observations in multiple entries over several weeks. The DON confirmed that the restraint box should have been checked and relevant behaviors or observations should have been documented, but this was not done. The facility's own policy required that all services provided, progress toward care plan goals, and any changes in the resident's condition be documented objectively, completely, and accurately, which was not followed in this case.