Failure to Document Restorative Nursing Services
Penalty
Summary
The facility failed to ensure complete and accurate documentation of Restorative Nursing Assistant (RNA) services for one resident. The resident, who had diagnoses including osteoarthritis in both knees and a history of stroke, was admitted with physician orders specifying RNA services for ambulation with a front wheel walker five times a week. Review of the resident's medical record showed only four RNA entries for March and no entries for April, despite the ongoing order for daily services on weekdays. During an interview and record review, the RNA stated that documentation should be completed after providing or attempting RNA services, including noting if the resident refused. The Director of Nursing confirmed the absence of documentation for RNA services from March 9 through the end of April. Facility policies reviewed indicated that appropriate documentation is required to address program goals and resident tolerance, as well as to provide a complete account of care and treatment.