Incomplete Documentation of Resident Repositioning
Penalty
Summary
The facility failed to ensure that clinical records for three residents were complete and accurately documented, specifically regarding the required turning and repositioning of residents. For one resident, the care plan required turning and repositioning every two hours, but clinical records lacked documentation of this intervention on multiple days and shifts throughout the month. Another resident's care plan also required turning and repositioning every two hours, yet there was no documented evidence of this being performed for the entire month. A third resident, with a diagnosis of femur fracture and stroke, had a care plan specifying turning and repositioning every two hours as tolerated, but no documentation was found for these interventions during the review period. Interviews with the residents and the Director of Nursing confirmed the absence of documentation for the required care. One resident stated she could self-reposition but needed extra help at times, while the DON acknowledged that the documentation should have been present but was not. The findings were based on reviews of clinical records, care plans, and staff interviews, and were cited under relevant state regulations for clinical records and nursing services.