Incomplete Documentation of Care and Delayed Hospice Notes
Penalty
Summary
The facility failed to ensure timely and complete documentation of care and provider notes for multiple residents. For one resident with multiple complex medical conditions, nurses did not sign the Medication Administration Record (MAR) to indicate administration of a scheduled thyroid medication on two separate days, leaving the documentation incomplete. Staff confirmed that MARs should not be left blank and emphasized the importance of maintaining accurate and complete records. Additionally, for two residents receiving hospice care, the facility did not ensure that hospice provider notes were added to the residents' records in a timely manner. In both cases, the last hospice note available was from over three weeks prior, with no documentation of subsequent hospice visits. Staff interviews confirmed that hospice visits occurred more frequently and that it was expected for these notes to be promptly available in the residents' records to ensure accessibility for care staff and providers.