Incomplete Documentation of Pain Management and Skin Assessments
Penalty
Summary
The facility failed to maintain complete and accurate medical records for two residents, specifically in the areas of pain assessment, medication administration documentation, and weekly skin assessments. For one resident with severe cognitive impairment and multiple diagnoses including Alzheimer's disease and osteoporosis, pain assessments were documented as '0' on the Medication Administration Record (MAR) and Nursing Medication Administration Record (NMAR) during periods when staff interviews and progress notes indicated the resident exhibited signs of pain, such as grimacing and moaning. Despite staff acknowledging the resident's pain and administering Tylenol, the MAR entries for the administration of this PRN pain medication were left blank, and staff could not consistently recall or explain the lack of documentation. Additionally, the same resident's weekly skin assessments were not documented in the electronic medical record (EMR) for two of fourteen weeks, despite orders requiring weekly assessments. Staff interviews revealed confusion regarding the process for documenting skin assessments, with some nurses indicating that assessments may have been performed but not entered into the correct section of the EMR. The facility's management confirmed that if the MAR was checked as administered, it was assumed the assessment was done, but acknowledged that missing documentation in the assessment tab meant the findings were not recorded. A second resident, who was moderately cognitively impaired and at risk for pressure ulcers, also had missing documentation for weekly skin assessments for three weeks. While the MAR indicated that assessments were administered, there were no corresponding entries in the EMR assessment tab or progress notes for those weeks. Staff interviews suggested that assessments may have been completed but not documented, and management did not believe the lack of documentation impacted care, as they relied on the MAR check-off and the presence of a treatment nurse. Facility policies required comprehensive documentation of pain assessments, medication administration, and skin assessments, but these were not consistently followed.