Failure to Maintain Accurate Documentation and Assessment per Professional Standards
Penalty
Summary
The facility failed to maintain accurate accountability and documentation for the management and administration of specific medical treatments and assessments as required by professional standards and facility policy. In one instance, a resident with complex medical needs did not have consistent or accurate documentation regarding the administration and monitoring of a prescribed medication. The Medication Administration Record (MAR) and electronic MAR (eMAR) contained multiple entries where the required volume of medication was not documented, or incorrect information such as hours instead of volume was recorded. Interviews with nursing staff confirmed that documentation was incomplete or not performed as required, and that staff were not always clear on the procedures for monitoring and documenting the medication administration. There was also a period where the resident may not have received the prescribed medication, and documentation did not reflect communication with the physician or pharmacy during this time. In another case, a resident was admitted with a specific medical condition that required ongoing assessment and documentation. The medical record review revealed that required assessments were not completed on admission, after a change in condition, or weekly as ordered. The facility's own policies required full body assessments upon admission, daily for three days, and weekly thereafter, as well as after any change in condition or identification of a new issue. However, the medical record did not contain evidence that these assessments were performed or documented as required. Interviews with staff confirmed that these assessments should have been completed and documented, and that incident reports and progress notes were also required when new issues were identified. Facility policies on administration of medications and documentation were reviewed and found to require complete, objective, and accurate documentation of all care provided, including medication administration details and patient assessments. Despite these policies, the facility did not ensure that staff consistently followed procedures for documentation and monitoring, leading to gaps in the medical record and a failure to meet professional standards of quality as outlined in federal and state regulations.
Plan Of Correction
483.21(b)(3) Comprehensive Care Plans 1. Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice: Resident 179 NJ Ex Order 26.4(b)(1) in the facility. Resident 178 NJ Ex Order 26.4(b)(1) in the facility. 2. Address how the facility will identify other residents having the potential to be affected by the same deficient practice: All residents have the potential to be affected by this deficient practice. 3. Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur: The Director of Nursing or designee in-serviced licensed nursing staff regarding creation of the comprehensive care plan, maintaining an accurate accountability for the management of [R], and accurate and timely completion of skin assessments. 4. Indicate how the facility plans to monitor its performance to make sure that solutions are lasting: The Director of Nursing or designee will audit 5 random residents for timely and accurate completion of skin checks. The Director of Nursing or designee will audit 5 random residents' charts for completion of comprehensive care plans. Audits will be conducted weekly x 4 weeks, then every other week for 4 weeks, and then monthly x 3 months. The results of the audit will be reported to the facility QAPI committee until compliance is determined to be sustained. F 658 The U.S. FOIA (b) (6) who stated that if a [R], he would have expected the facility to insert an [R] until they could get a [R] established. The stated that he would have expected for [R] to have been notified, preferably, to see what they wanted done. The [R] stated, '[R]' 2. The surveyor reviewed the medical record for Resident #178. A review of the Admission Record, an admission summary, revealed the resident had diagnoses which included, but were not limited to, [R]. A review of the resident's admission Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated [R], included the Brief Interview for Mental Status (BIMS) was not assessed [R]. A staff assessment for Mental Status included that the resident had [R]. Further review of the MDS revealed the resident was [R] and was F 658