Incomplete and Inaccurate Clinical Record Documentation for Multiple Residents
Penalty
Summary
The facility failed to ensure that clinical records were complete and contained accurate information for several residents, as evidenced by missing or incomplete documentation in multiple areas. For one resident, the care plan specified a preference for showers on certain days, but documentation showed only bed baths were provided over a three-week period, and there was no evidence that showers were offered or refused as required. Additionally, meal intake records for this resident were incomplete, with several meals lacking documentation despite the resident being at nutritional risk and under hospice care. A CNA reported not being aware of the resident's bathing preferences due to lack of information on the task sheet and not knowing how to access this information in the electronic medical record. Another resident with dental issues and a recent hip fracture had a care plan requiring oral hygiene to be offered twice daily, but records lacked evidence that this was done or refused on multiple days. For a resident with Parkinson's and anxiety disorder receiving end-of-life care, documentation of meal offerings was missing for several meals. Furthermore, for a resident requiring two-person assistance for toileting due to a hip fracture and confusion, there was no documented evidence of appropriate toileting assistance during admission. Staff interviews revealed that documentation was often completed at the end of shifts rather than in real time, despite in-service training on timely ADL documentation.