Incomplete and Inaccurate Documentation of 15-Minute Monitoring Checks
Penalty
Summary
The facility failed to ensure that medical records were complete and accurate for three residents who required 15-minute monitoring due to various clinical concerns, including suicide risk and post-fall observation. For one resident with a recent stroke and identified as being at moderate to high risk for suicide, staff failed to perform and document required 15-minute checks during a period when the assigned CNA was on break. Despite this, the monitoring log was later found to have documentation for the missed times, indicating inaccurate recordkeeping. The Resident Care Manager confirmed that staff are expected to document only the tasks they personally complete, and that this expectation was not met. For two other residents, both of whom were placed on 15-minute checks following falls, the monitoring logs showed incomplete documentation for required observation periods. In one case, the log was blank for a significant portion of the day, while the MAR indicated the checks had been completed. In the other case, there was a gap of several hours with no documentation of checks. The Resident Care Manager acknowledged these discrepancies and stated that it was not acceptable to document checks that were not performed or to leave required checks incomplete.