Incomplete and Inaccurate Documentation of Resident Interactions and Activities
Penalty
Summary
The facility failed to ensure that documentation in resident medical records was complete and accurate, specifically regarding care-planned interactions between two cognitively intact residents and the documentation of activities for another resident. In the case of two residents who were care planned for bickering, progress notes described a 'fight' during supper but did not clarify whether the altercation was physical or verbal, who was involved in cursing, the impact of the interaction, or what actions staff took during or after the event. Interviews with the DON, Executive Director, and the RN responsible for the documentation revealed that language barriers contributed to unclear and potentially inaccurate charting, with the RN acknowledging difficulties with English and terminology in his documentation. Further review showed that both residents involved in the altercation had a history of similar interactions, and both reported no concerns about abuse, describing their disagreements as typical and transient. The facility's management was aware of the ongoing behavior and had care plans in place, but the documentation failed to provide objective, detailed accounts of the incidents as required by facility policy. The DON and ED confirmed ongoing issues with the RN's documentation accuracy due to language challenges, and the facility's process included daily reviews of documentation to identify such issues. Additionally, the facility failed to maintain complete activity records for another cognitively intact resident with major depressive disorder and diabetes. Documentation showed that activities were not recorded for seven out of the last thirty days, despite the resident's report of attending all available activities. The Activities Director confirmed that it was the responsibility of activities staff to document participation, and that passive and interactive activities were provided daily. The facility's policy required documentation to be objective, complete, and accurate, which was not met in these instances.