Incomplete Clinical Documentation and Missing Incident Records
Penalty
Summary
The facility failed to ensure that clinical records for two residents were complete and accurately documented, as required by accepted professional standards. For one resident with moderate cognitive impairment and a history of falls, nurse aide documentation was missing for multiple days in June for essential care tasks such as bed mobility, snacks, continence, fluid intake, hygiene, toilet use, and transfers. For another resident, also with moderate cognitive impairment and a history of falls, there was no documentation in the clinical record of two separate fall incidents or of registered nurse assessments following those falls. Additionally, nurse aide documentation for daily care tasks was missing on numerous shifts across May and June. Interviews with the Director of Nursing confirmed that both residents received their care, but staff failed to document the care provided in the clinical records as required. The lack of documentation included both routine care and incident-related assessments, specifically after falls, which were not recorded in the clinical records. These findings were based on reviews of clinical records, facility investigations, and staff interviews.