Inaccurate and Unclear Documentation of Restorative Nursing Aide Services
Penalty
Summary
The facility failed to ensure that Restorative Nursing Aide (RNA) services were accurately documented for three residents. For each of these residents, the RNA daily documentation did not clearly reflect whether services were provided, missed, or not applicable, due to the use of unclear notations such as 'n, n, n' or 'n, n' in the electronic medical record. Staff interviews revealed that these notations were used inconsistently to indicate either that prompts did not pertain to the RNA task or that the resident was not seen for RNA treatment, but there was no standardized understanding or guidance on their use. This led to confusion among staff, including the Assistant Director of Nursing (ADON), Medical Records Director (MRD), and Director of Nursing (DON), all of whom were unable to determine from the documentation whether RNA services had actually been provided on specific dates. For one resident with a history of left femur fracture and gout, the RNA flowsheets indicated scheduled walking exercises and range of motion (ROM) activities, but the documentation was unclear as to whether these services were performed. The resident was observed to have significant physical limitations and required substantial assistance with daily activities. Staff interviews confirmed that the documentation process was confusing, and it was not possible to determine from the records if the resident received or missed RNA sessions on several dates. Another resident with right-sided hemiplegia, legal blindness, and sepsis had RNA documentation for walking exercises that also used the unclear 'n, n, n' notation. The resident reported inconsistent assistance with exercises, and staff again could not confirm from the documentation whether services were provided on certain dates. A third resident, who required a splint applied to the right elbow, had RNA documentation prompts that did not match the actual RNA task, leading to further confusion. The facility's policy required that all services provided be documented objectively, completely, and accurately, but the observed documentation practices did not meet these standards.