Failure to Document Restorative Nursing Treatments in Resident Record
Penalty
Summary
The facility failed to maintain accurate and complete clinical records for one resident by not properly documenting the delivery of Restorative Nurse Aide (RNA) treatments. Specifically, the Restorative Nursing Records for the resident showed missing signatures and no indication of whether scheduled RNA treatments for upper extremity active range of motion and ambulation with an assistive device were provided or refused on multiple dates. The lack of documentation occurred despite the resident having diagnoses including Parkinson's disease, acute respiratory failure with hypoxia, and dysphagia, and being assessed as having intact cognition and independence in activities of daily living. Interviews with facility staff, including the Director of Staff Development and the Director of Nursing, confirmed that RNA staff were expected to sign or document on the Restorative Nursing Record if the resident received or refused treatment, or if the resident was unavailable. The facility's policy required that documentation related to physician orders be maintained in the resident's medical record, with current month's administration records kept in the appropriate binders. The failure to document RNA treatments as required led to incomplete clinical records for the resident.