Incomplete and Inaccurate Resident Records and Documentation
Penalty
Summary
The facility failed to ensure that resident records were complete and accurate for four residents, resulting in deficiencies related to medication orders, documentation, and monitoring. For one resident, a multivitamin order incorrectly included instructions to monitor for combative behavior, which staff confirmed was entered by mistake and did not reflect the resident's needs. Another resident receiving insulin glargine had orders that lacked required parameters for when to hold the medication or notify the provider, contrary to facility policy and staff expectations. A third resident's Preadmission Screening and Resident Review (PASARR) form was found to be incomplete, as it did not document a diagnosis of depression that was present on the resident's face sheet. Staff acknowledged that the PASARR form should have been updated to accurately reflect the resident's diagnosis, in accordance with facility policy. Additionally, a resident's bed positioning device was observed to be loose on multiple occasions, but the facility's room rounds form did not specifically list or document regular inspection of bed positioning devices. Staff indicated that these devices were considered part of the bed or furniture and were checked under general room or furniture repair sections, but the documentation did not specifically address the condition or monitoring of the positioning device.