Incomplete Clinical Documentation and Missing Provider Orders for Lab Studies
Penalty
Summary
Facility staff failed to maintain complete and accurate clinical records for two residents. For one resident, the medication administration record (MAR) indicated two episodes of behaviors during specific shifts, but the clinical documentation did not specify what those behaviors were. Additionally, the MAR included a section for monitoring and documenting specific behaviors, which was inconsistently completed; the nurse documented 'N' for no behaviors observed, which did not clarify the nature of the behaviors previously recorded. Facility policy required documentation of all services, changes in condition, and events involving the resident, but this was not followed in this instance. For another resident, staff did not ensure that the clinical record included a provider order for laboratory studies that were performed. Although a progress note indicated that a provider requested a urinalysis due to concerns about cloudy urine, and results for both urinalysis and urine culture were present in the record, there was no formal provider order documented in the system. The DON confirmed the absence of a provider order for these laboratory studies, despite the tests being completed and results available.