Failure to Document Resident Care in Point of Care System
Penalty
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.