Failure to Accurately Document Medication Use and Restorative Care Refusals
Penalty
Summary
The facility failed to maintain complete and accurate documentation in the medical records for two residents. For one resident with diagnoses including dementia, schizoaffective disorder, and major depressive disorder, the Nursing Summary Weekly did not accurately reflect the use of prescribed antipsychotic and antidepressant medications, despite physician orders and the Medication Administration Record confirming daily administration of these medications. Both the LVN and DON confirmed that the Nursing Summary Weekly was inaccurate and should have indicated the resident was receiving these medications. The facility did not have a specific policy on nursing documentation or charting, but the existing policy required comprehensive and accurate documentation of resident assessments and care. For another resident with left-sided hemiplegia, hemiparesis, left hand contracture, and a left above-knee amputation, the facility failed to accurately document refusals of Restorative Nursing Assistant (RNA) treatments. Although the resident frequently refused RNA services, the RNA daily flowsheets and weekly summaries consistently indicated that the resident was seen for treatment five times a week with zero refusals. Interviews with the RNAs and the DSD confirmed that the resident refused RNA services at least one to two times daily, but these refusals were not documented as required. The RNAs admitted to ceasing documentation of refusals due to their frequency, and the DSD acknowledged awareness of the ongoing refusals and the lack of accurate documentation. The facility's policy on RNA services required appropriate documentation of the resident's tolerance and participation in the program. However, the failure to document refusals and actual services provided resulted in an inaccurate reflection of the care delivered and the resident's response to the RNA program. This lack of accurate documentation was confirmed by multiple staff members and was evident in the resident's medical records.