Failure to Accurately Document Abuse Incidents and Resident Assessments
Penalty
Summary
The facility failed to ensure accurate and complete documentation in the medical records for six residents in relation to abuse incidents, resident assessments, and the safeguarding of resident-identifiable information. For one resident with end-stage renal disease and multiple comorbidities, there was no evidence that staff completed required assessments before or after dialysis treatments, despite care plan interventions and policy requirements. Interviews with nursing staff and the DON revealed that while some monitoring was claimed to occur, there was no documentation in the medical record to support that assessments, including fistula site checks, were performed as required. Several residents involved in physical altercations did not have any documentation in their medical records regarding these incidents, even though the facility had reported the events to the state agency. The DON confirmed the absence of documentation for these altercations in the clinical records of the affected residents. Additionally, for a resident who reported a missing ring and alleged misappropriation of property, there was no documentation of the incident or the allegation in the clinical record, nor was the missing item recorded on the resident's inventory sheet. Policy reviews indicated that the facility's procedures required documentation of all services, incidents, and changes in resident condition in the medical record, as well as specific protocols for documenting abuse, neglect, and misappropriation allegations. Despite these policies, the facility did not maintain complete and accurate records for the identified residents, as confirmed by staff interviews and record reviews.