Failure to Document Resident Care in Point of Care System
Summary
Facility staff failed to consistently document care provided to a resident in the "Documentation Survey Report v2 (DSR)" and did not follow the facility's policy on Point of Care (POC) documentation. Specifically, for one resident, there were multiple instances where documentation was missing for care provided across several dates and shifts. The electronic medical record review revealed blank spaces in the POC documentation, indicating that care was either not provided or not recorded as required. Interviews with staff, including LPNs and other facility personnel, confirmed that the expectation is for CNAs to document all activities of daily living (ADLs) in the POC system for every shift. Staff stated that refusals of care should be documented in both the care plan and progress notes, and that blank spaces in the POC indicate a failure to document. The staff also acknowledged that the facility's policy was not followed, as documentation was missing for the identified periods. The facility's policy requires CNAs to document resident care in accordance with each resident's individualized plan of care, including self-performance and support for ADLs such as toileting and personal hygiene, as well as bowel and bladder continence. The lack of documentation for the resident in question was confirmed by both record review and staff interviews, establishing that the required documentation was not completed as per policy and regulatory requirements.
Plan Of Correction
1. Resident #2 was assessed that NJ Ex Order 26. 4B1 was provided by licensed nursing staff. The residents continue to receive appropriate care per the plan of care. 2. All residents have the potential to be affected by incomplete or inconsistent documentation by not documenting that incontinent care was provided. A facility-wide audit was completed to ensure POC is completed for all current residents. Any inconsistencies were addressed immediately, and all charts were updated accordingly. 3. All Certified Nursing Assistants were re-educated on the facility's policy titled "Point of Care (POC) Documentation," with emphasis on timely and complete documentation of care tasks, including incontinence care and toileting hygiene. Education will be completed on orientation and as part of annual competencies. 4. The Director of Nursing (DON) or designee will conduct daily audits of POC documentation prior to CNA end of shift for all residents for 5 consecutive days, followed by weekly audits for 3 weeks, and then monthly audits for 3 months. Results of the audits will be documented and reviewed during the facility’s monthly QAPI (Quality Assurance and Performance Improvement). The QAPI Committee, comprised of the NHA, DON, Infection Preventionist, and Medical Director, will oversee the effectiveness of these interventions and recommend additional actions if necessary.
Penalty
Resources
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The facility failed to keep complete and accurately documented clinical records for two residents. One resident had conflicting MD/NP notification orders for elevated blood glucose, with one order to notify for BS >250 and another sliding-scale insulin order directing a call if BS was >400. Another resident’s facesheet omitted insomnia and anxiety diagnoses even though the care plan and psych services note documented those conditions; the DON confirmed outside-provider diagnoses should have been included in the record and facesheet.
A resident receiving PT had multiple scheduled therapy sessions with no documentation in the service log matrix. The resident said therapy had been inconsistent, and the DON of Therapy acknowledged missed sessions without recorded reasons, stating the therapist should have documented why the sessions were not completed. The resident later said he had missed therapy when he was not feeling well and that the therapist had been sick once.
Failure to Document Ordered Skin Treatments: The facility failed to accurately document ordered skin treatments for a resident with a great toe condition. The MAR and TAR did not show the ordered Epsom salt soaks or triple antibiotic ointment, even though the DON, an LPN, the wound care nurse, and the resident stated the treatments were provided. Facility policy required all medications administered to be documented on the MAR immediately after administration.
Inaccurate Face Sheet Diagnosis Documentation: A resident’s face sheet failed to list pain as a diagnosis even though the H&P, care plan, and physician orders all reflected ongoing pain management, including scheduled morphine. The resident reported chronic pain from an old military back injury, and the MDS nurse acknowledged the diagnosis had not been entered on the face sheet and that diagnoses had not yet been audited against the H&P.
Incomplete influenza vaccination records were found for two residents. The EMR had no evidence that either resident was offered, received, or declined the 2025 influenza vaccine. Interviews showed an RN who had been assigned resident vaccination responsibilities destroyed the vaccine consents/records, and the HIM confirmed the influenza information was not entered into the EMR.
Incomplete documentation of elevated heart rate and medication administration. A resident with cerebral infarction, HTN, atherosclerotic heart disease, and inappropriate sinus tachycardia had a documented HR of 122 bpm, but the record did not show a reassessment or any documentation of symptoms later that day. The MAR also showed evening meds as not given because the resident had died, while an RN stated the meds were actually given earlier and the DON confirmed the record did not match the nurse’s statement.
Incomplete Clinical Records and Missing Diagnoses
Penalty
Summary
The facility failed to maintain complete and accurately documented medical records for 2 residents reviewed. For one resident with diagnoses including unspecified dementia, type 2 diabetes mellitus, and heart failure, the clinical record contained conflicting blood glucose notification orders: one order directed staff to notify the MD/NP if blood sugar was less than 90 or greater than 250, while another order for sliding-scale insulin stated to give 10 units if blood sugar was greater than 400 and call the MD. The resident also had a BIMS score of 6, indicating severe cognitive impairment, and the care plan identified diabetes mellitus. For another resident with vascular dementia, cerebral infarction, and paranoid personality disorder, the facesheet did not include diagnoses of insomnia and anxiety. The resident’s care plan stated the resident used anti-anxiety medications due to anxiety disorder, and a psychological services progress note listed diagnoses of primary insomnia and anxiety disorder. The DON confirmed that the diagnoses from outside providers should have been included in the facility clinical record and on the facesheet, and also confirmed that the facesheet was used to communicate the resident’s status to hospitals and other outside providers.
Missing Documentation for Scheduled Therapy Sessions
Penalty
Summary
The facility failed to document therapy sessions for one resident receiving rehabilitation services. The resident stated during interview that he wanted to know whether he would have therapy that day and reported that the physical therapist had been on vacation and that he had not received therapy in weeks. Review of the physician order showed a PT recertification order for treatment every day, one time per week for 60 days, including therapeutic exercise, therapeutic activity, gait training, and caregiver education for diagnosis R53. The resident’s service log matrix showed no documentation for therapy visits on 4/14/2026, 4/28/2026, and 5/19/2026. During interviews, the Director of Therapy acknowledged that the resident missed the listed dates and stated there was no documentation explaining why the sessions were not completed. The Director of Therapy said the resident was on the assignment board for functional maintenance and that, for whatever reason, if the resident refused or was not feeling well, it was not documented. The Director also stated the therapist was in Thailand and could not communicate about what happened, and that the therapist should have documented the reasons the therapy sessions were not completed. The resident later stated he had missed therapy once or twice because he was not feeling well and that his therapist had been sick once, with someone else sent in that time. The facility policy required resident care documentation to be maintained in a complete, timely, and orderly fashion.
Failure to Document Ordered Skin Treatments
Penalty
Summary
The facility failed to accurately document treatments ordered for Resident #112, who had a physician order dated 4/6/2026 for daily Epsom salt soaks for 14 days and application of triple antibiotic ointment to the great toe. Review of the resident’s Medication Administration Record and Treatment Administration Record for April 2026 did not show documentation of either the Epsom salt soaks or the triple antibiotic ointment to the great toe. During interviews, the DON stated the order existed but was not documented and that she could not find it in the treatment records, although staff said they had provided the care. An LPN stated she saw nursing provide the treatment and that the Epsom salt remained in the medication cart, adding that staff wrote the order but forgot to check off the box so it would appear on the MAR. The wound care nurse stated she was doing the treatments daily for Resident #112, and the resident confirmed staff provided the Epsom salt soaks and triple antibiotic ointment. The facility policy stated that the MAR is used to document all medications administered and that administration is documented immediately after it is given.
Inaccurate Face Sheet Diagnosis Documentation
Penalty
Summary
The facility failed to ensure that Resident #28’s medical record was accurately maintained in accordance with accepted professional standards because the resident’s face sheet did not include a diagnosis of pain. Record review showed the resident was a [AGE]-year-old male admitted on [DATE] and remitted on 7/23/2025 with diagnoses including bipolar disorder, dementia, and diabetes. The face sheet dated 6/3/26 did not list pain as a diagnosis, even though the resident’s history and physical dated 4/23/2025 documented pain, and the care plan had a focus on pain. Additional record review showed the resident’s June 2026 physician orders included Morphine Sulfate 30 mg, one tablet twice daily, and the resident stated he had experienced pain for years due to an old military back injury. The BIMS assessment completed 5/13/26 showed a score of 14, indicating intact cognition. The MDS nurse stated she was responsible for entering diagnoses on face sheets and that the pain diagnosis had not been entered, and she had not yet audited diagnoses against the corresponding histories and physicals. The ADON stated he had been in his role for two months and had not yet audited all prior admissions for face sheet accuracy. The facility policy stated documentation in the medical record would be objective, complete, and accurate.
Incomplete influenza vaccination records
Penalty
Summary
The facility failed to ensure complete clinical records for two residents reviewed for vaccination status. For one resident admitted on 07/29/25 and another admitted on 08/05/21, there was no evidence in the EMR that either resident was offered, received, or declined the 2025 influenza vaccine. The missing documentation was identified during clinical record review and involved the residents' vaccination status in the record. During interviews, the DON stated that RN4 destroyed the 2025 consents and records for the influenza vaccines, and the Administrator stated that RN4 destroyed all records associated with the 2025 influenza vaccination status. The HIM stated that the IP was typically responsible for resident vaccination data and that RN4 should have entered the influenza information into each resident's EMR, but this was not done. The DON also stated she had delegated resident vaccination responsibilities to RN4 when he was hired, and a facility policy on retention of medical records indicated discharged residents' medical records were to be retained for 7 years from the date of service.
Incomplete Documentation of Elevated Heart Rate and Medication Administration
Penalty
Summary
The facility failed to maintain complete and accurate medical records for one resident. Resident #2 was admitted with diagnoses including cerebral infarction, hypertension, atherosclerotic heart disease, and inappropriate sinus tachycardia. The resident’s heart rates from one period in the record ranged from 57 to 89 bpm, but the MAR documented a heart rate of 122 bpm at 9:00 AM on one date. Nursing progress notes, evaluations, and the vital sign section of the electronic medical record did not show that the resident’s heart rate was reassessed between 9:00 AM and 8:00 PM, and there was no documentation about whether the heart rate decreased or whether the resident had symptoms related to the elevated heart rate. The MAR also showed that at 8:00 PM the medications Atorvastatin, Famotidine, Metoprolol, and Acetaminophen were signed off as not given because the resident had passed away suddenly. However, a change in condition note documented that the resident was assessed with no pulse, no BP, and no respiration at 10:00 PM, with a code blue and 911 called, and paramedics continuing CPR until the resident was pronounced deceased at 10:36 PM. RN #12 stated she gave the evening medications at 9:00 PM but did not sign the MAR until later, and the DON confirmed that the medical record did not reflect the medications were given or the resident’s status as described in the nurse’s statement.
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