Inaccurate Documentation of Restorative Nursing Services
Penalty
Summary
The facility failed to ensure accurate and complete medical record documentation for a resident with range of motion (ROM) and mobility concerns. Specifically, the Restorative Nursing Aide (RNA) services provided to the resident were not properly documented, as the records did not accurately indicate which RNA performed active assistive range of motion (AAROM) exercises and sit-to-stand transfers on multiple dates. Review of the facility's sign-in sheets and payroll records revealed that the RNAs who initialed the records for providing services were not present or did not work on those dates. Additionally, there were inconsistencies between different versions of the resident's restorative nursing records, including future discontinue dates and discrepancies in which staff were documented as providing care. The resident in question had a medical history including muscle weakness, diabetes mellitus, peripheral vascular disease, and difficulty walking. Physician orders required the RNA to provide AAROM to both arms and legs and to assist with sit-to-stand transfers using a front wheeled walker, with changes to the orders over time as the resident's condition evolved. Observations and interviews confirmed that the resident received ROM exercises and that the resident was aware of some changes in their care, but was not always informed about discontinuation of certain services. During direct observation, the resident demonstrated limited ROM in the right hand and more active movement in the left, and described a history of using assistive devices for mobility. Interviews with RNAs and facility leadership confirmed that staff sometimes initialed records for each other or for dates they did not work, and that there was no policy or procedure in place for accurate medical record documentation. The Director of Nursing acknowledged that the medical record is a legal document and that only the staff providing the treatment should sign the record. The lack of accurate documentation resulted in incomplete and inaccurate medical records for the resident's restorative nursing services.