Failure to Consistently Document Resident Care in Accordance with Policy
Penalty
Summary
Facility staff failed to consistently document care provided to a resident in accordance with the facility's Charting and Documentation policy and accepted professional standards. Specifically, review of the Documentation Survey Report (DSR) for one resident revealed blank entries for the type of assistance provided on multiple shifts, despite the expectation that all care should be documented without omissions. The resident in question had a history of neoplasm of the prostate, anxiety disorder, and acute kidney failure, and was assessed as moderately cognitively impaired. The care plan indicated an ADL Self Care Performance Deficit, yet documentation was incomplete for several shifts. Interviews with staff, including a CNA, the Unit Manager, the Administrator, and the Interim DON, confirmed that CNAs were responsible for documenting all care in the electronic system and that nursing management was expected to ensure documentation was complete. The facility's policy, reviewed in March 2025, required that all services provided to residents be fully and accurately documented. The presence of blank entries in the DSR indicated a failure to adhere to these requirements.
Plan Of Correction
1) How the corrective action will be accomplished for those residents found to have been affected by the deficient practice. The facility met with resident #4 to ensure all ADL care was provided as scheduled on ADL record. The nurses and nursing assistants of resident #4 were educated on the performance and documentation of Activities of Daily Living on the electronic ADL record 2) How the facility will identify other residents having the potential to be affected by the same deficient practice. The facility recognizes that all residents have the potential to be affected by this deficient practice 3) What measures will be put into place or systematic changes to ensure that the deficient practice would not recur The facility Director of Nursing or designee will provide education to all Nurses and Nursing Assistants on completion and documenting of all resident Activities of Daily Living completed in the electronic ADL record 4) How the facility will monitor its corrective actions to ensure that the deficient practice is being corrected and will not recur, i.e. what program will be put into place to monitor the continued effectiveness of the systemic change The facility Director of Nursing or designee will audit resident electronic ADL records weekly for three months and then monthly for three months on different shifts to ensure ADLs are being completed and documented as appropriate on the ADL electronic record The Director of Nursing or designee will present the findings of the audits and review trends and needed follow up in the two facility Quarterly Quality Assurance Performance Improvement Meetings