Incomplete and Inaccurate Medical and Facility Recordkeeping
Penalty
Summary
The facility failed to maintain complete and accurate medical and facility records for multiple residents and the Resident Council, as required by federal regulations. For one resident, there was conflicting documentation regarding the administration time of olanzapine zydis 5 mg, an antipsychotic medication. The physician's order specified administration at noon, but the scheduling details listed both 0900 and 1200 hours. This discrepancy was confirmed by a licensed vocational nurse, who acknowledged that the 0900 time was inaccurate and not in accordance with the physician's order. Additionally, the facility did not ensure complete documentation of the Resident Council Agenda/Minutes for several months. While issues raised by the Resident Council and departmental responses were recorded, the sections indicating whether the issues had been resolved to the residents' or families' satisfaction were left unchecked for multiple months. Interviews with residents confirmed that their concerns had been resolved, but the documentation did not reflect this follow-up, and the Activities Director acknowledged responsibility for this incomplete recordkeeping. For another resident who was discharged, the Notice Proposed Transfer/Discharge form was not accurately completed. The form lacked the required signature of the resident or their representative and listed a different hospital destination than the one specified in the physician's transfer order. Both a licensed vocational nurse and a registered nurse verified these discrepancies, and facility leadership acknowledged the findings. These documentation failures resulted in inaccurate records regarding resident care and facility operations.
Plan Of Correction
The corrective action(s) accomplished for the residents found to have been affected by the deficient practice: Resident 171 and 195 were affected by this deficient practice. On 07/21/2025, the Unit Manager clarified the medication scheduling record and notified the pharmacy to send medication with the correct label. Resident 195 is no longer residing in the facility. On 7/16/2025, the Administrator provided 1:1 education to the Activity Director about facility policies and procedures for ensuring accurate documentation on the resident council agenda/minutes record, particularly reviewing and following up on resident council grievances. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All residents were potentially affected by this deficient practice. On 8/4/2025, the DON and Unit Manager audited 10 random residents' Medication Administration Records and found no other issues noted. On 8/4/2025, medical records were audited for the last 30 days of transfer and discharge records, and no other issues with the completion of notification of transfer/discharge records were found. On 7/16/2025, the Activity Director reviewed all resident council meeting minutes from the last 4 months and followed up on any grievances, all of which were addressed. From 8/5/2025 to 8/8/2025, the Director of Nursing (DON) or designee in-serviced all Licensed Nurses about the facility policies and procedures for documentation accuracy and ensuring medication labels were correct based on physician orders. On 8/5/2025, the Administrator in-serviced Social Services and the Case Manager about the facility policies and procedures for completing and signing proposed notification of discharge/transfer forms. Measures that will be put into place or systematic change the facility will make to ensure that the deficient practice does not recur: The DON and Administrator or designee will oversee this process. The RN supervisor or designee will review all new admissions and re-admissions to verify that all orders, particularly medication administration times, are confirmed with the primary physician and that the pharmacy is notified of any label discrepancies. The Unit Manager or designee will review 24-hour and 72-hour summary reports and report during clinical meetings for any non-compliance. The Administrator or designee will review all resident council agenda minutes to ensure they are completed accurately, and all grievances are addressed and followed up before signing. Medical records will be audited daily after resident discharge or transfer to ensure all necessary information is completed and signed. Any non-compliance will be reported to the Administrator and DON during the morning meetings (Monday through Friday) for three months. Facility plans to monitor the effectiveness of the corrective actions and sustain compliance: The DON and Administrator will monitor the effectiveness of the process and report any findings at the Monthly QA&A meeting. The Plan of Correction was presented at the Quality Assurance (QA&A) committee meeting on 08/14/2025. Ongoing findings from audits will be reported to the QAPI/QAA monthly meetings for at least three months. Corrective action completion date: 8/23/2025 --- The corrective action(s) accomplished for the residents found to have been affected by the deficient practice: Resident 120 was affected by staff not performing hand hygiene between glove changes during treatment. On 7/18/2025, the DON provided 1:1 education to LVN 11 about facility policy and procedures for infection control and prevention, especially emphasizing hand hygiene between glove changes during wound treatment to prevent cross-contamination. Resident 162 was affected by this deficient practice. Immediately on 7/15/2025, LVN 9 changed the isolation sign from EBP to contact isolation. All residents were affected by soiled laundry stored in the clean laundry area. On 7/18/2025, the Infection Prevention (IP) nurse in-serviced all laundry staff about facility policies and procedures for cross-contamination prevention and proper separation and storage of clean and soiled laundry.