Failure to Timely Document APRN Visit and Assessment
Penalty
Summary
A deficiency occurred when the facility failed to ensure complete and timely documentation in the medical record for a resident with hemiplegia, aphasia, and severe cognitive impairment. The resident required assistance with activities of daily living (ADLs) and was always incontinent. On a specific date, an LPN identified that the resident had not received timely incontinent care, and this was documented in an incident report. Despite the identification of omitted care, no RN assessment was performed from the time the issue was discovered until the end of the shift. Additionally, an APRN evaluated the resident's skin condition nearly two days after the omitted care was identified, but did not document the visit until 17 days later as a late entry. Both the APRN and the Director of Nursing confirmed that the note should have been written at the time of the visit, in accordance with the facility's documentation policy, which requires documentation at the time of service or by the end of the shift. The failure to document the APRN visit in a timely manner resulted in an incomplete and inaccurate medical record for the resident.