Failure to Accurately Complete Safety Evaluation and Maintain Clinical Records
Penalty
Summary
Facility staff failed to accurately complete and document a hot liquid safety evaluation for a resident with a history of agitation, restlessness, and impulsive behavior. Despite multiple progress notes indicating the resident was agitated and required lorazepam in the week prior to the evaluation, the hot liquid safety form did not reflect these behaviors. Required sections indicating risk factors were not properly checked, and the form was left incomplete, omitting the necessary indication that the resident was at risk for injury from hot liquids. Additionally, staff failed to maintain accurate clinical records for another resident who was dependent for activities of daily living and had severe cognitive impairment. There were conflicting accounts regarding whether the resident received a shower, with CNA documentation indicating a shower was given, while statements from other staff, including an LPN and a physical therapist assistant, indicated the resident was not showered. The resident's daughter also reported that her father did not appear to have been showered, providing photographic evidence of poor hygiene and soiled bedding. The facility did not have a policy for activities of daily living documentation, and the inconsistencies in staff statements and documentation led to uncertainty about the care provided. The lack of accurate and complete clinical records for both residents was confirmed through staff interviews, clinical record reviews, and supporting documentation.