Failure to Accurately Document and Provide Restorative Nursing Services
Penalty
Summary
The facility failed to accurately document and provide restorative nursing services (RNS) as ordered for several residents, resulting in incomplete and inaccurate medical records. For one resident with diagnoses including gait abnormalities and dementia, there was a physician's order for ambulation assistance three times per week, but the resident did not receive any RNS for the entire month as required. Despite this, the Restorative Nursing Assistant (RNA) was instructed by the Director of Nursing (DON) to sign the treatment record for the month, resulting in documentation that falsely indicated services were provided. The RNA later stated that the DON directed them to 'fix the mistake' by signing the record, and the DON acknowledged a miscommunication between nursing, RNA, and rehabilitation staff regarding the new order. Additionally, the facility failed to ensure that documentation on the Restorative Nursing Record (RNR) accurately reflected the provision of services for other residents. One RNA signed and initialed the RNR for two residents on a date when the RNA was not clocked in for work, and two other RNAs signed for services provided to another resident on dates when they were not present in the facility. These inaccuracies were confirmed through timecard reviews and staff interviews, where the involved RNAs admitted to signing for services they did not provide, either by accident or as directed. The facility's policy required accurate and timely documentation of restorative nursing services to ensure residents received appropriate care based on their assessments and physician orders. The failures in communication, documentation, and oversight led to medical records containing false information for multiple residents, which could affect their care and outcomes. The facility's own policy emphasized the importance of accurate documentation and prompt communication of significant changes or problems to the charge nurse.