Incomplete Documentation of Infection Monitoring
Penalty
Summary
The facility failed to ensure that medical records were complete and accurately documented regarding infection monitoring for two residents. For one resident with a history of stroke, hemiplegia, and severe cognitive impairment, the Medication Administration Record (MAR) indicated that monitoring for signs and symptoms of infection was required daily. However, on two specific dates, the MAR was marked as 'y' for infection monitoring, but there was no supporting documentation indicating the presence or absence of infection symptoms on those days. The Director of Nursing confirmed this was a documentation error, likely due to the nurse not understanding the correct documentation process. Similarly, another resident with diabetes, an acquired absence of the left foot, and moderate cognitive impairment also had a MAR requiring daily infection monitoring. On the same two dates, the MAR was marked as completed, but there was no additional documentation to support whether infection symptoms were present or absent. The Director of Nursing again identified this as a documentation error related to improper understanding of the documentation requirements.