Inaccurate Activity Documentation Due to Shared Staff Logins
Penalty
Summary
The facility failed to maintain accurate and complete medical records in accordance with accepted professional standards for two residents reviewed under the Activities care area. Specifically, activity documentation did not accurately reflect which activity staff member provided services to the residents. For both residents, records indicated that an activity assistant had signed for days when she was not present, and other staff members used her login credentials to document activities, rather than having their own access. One resident, admitted with dementia, major depressive disorder, and generalized muscle weakness, was dependent on staff for transfers and had a care plan emphasizing participation in religious services. Documentation for this resident showed that the activity assistant was recorded as providing services on days she was not working. The assistant confirmed she did not sign on those dates, indicating inaccurate recordkeeping. Another resident, with diagnoses including dementia, schizoaffective disorder, and COPD, also had activity records showing the same assistant's signature on days she was not present. Interviews revealed that other activity assistants did not have their own electronic charting access and used the assistant's login to document care. The DON confirmed that each staff member should have individual access to ensure accurate and validated documentation, and that signing for others is not accurate and poses confidentiality risks. Facility policies required that only authorized staff document in medical records and that staff may not sign for another person.