Failure to Accurately Document and Provide Restorative Nursing Services
Penalty
Summary
The facility failed to accurately document and provide restorative nursing services (RNS) as required for several residents, resulting in incomplete or falsified records. For one resident with orders for ambulation using a front wheel walker three times per week, the RNS was not provided for an entire month despite physician orders and care plan directives. The restorative nursing assistant (RNA) later signed the resident's record for that month at the direction of the Director of Nursing (DON), even though the services had not been rendered. The RNA stated that the DON instructed them to sign the record to correct the mistake, and the RNA complied due to the DON's authority, not realizing this constituted falsification of records. Additionally, the facility failed to ensure that RNAs only documented services they actually provided. For two other residents, the RNS records were signed by an RNA on a date when the RNA was not clocked in for work, indicating that the services were not actually performed. The RNA admitted to accidentally signing and initialing the records for those dates. Similarly, for another resident, three different RNAs signed the RNS record on dates when none of them were present at work, and each acknowledged during interviews that they had made mistakes in documentation or were unsure if the services were provided. The facility's policy required accurate and timely documentation of restorative nursing services, with staff expected to document and communicate any significant resident problems or changes. However, the review of timecards, interviews with staff, and examination of medical records revealed that the facility did not follow its own procedures, resulting in inaccurate records and a lack of required restorative care for multiple residents. The DON and Assistant DON were aware of discrepancies but did not ensure that the records accurately reflected the care provided.