Inaccurate Documentation of Restorative Care Services
Penalty
Summary
A deficiency occurred when a Restorative Nurse Aide (RNA) documented that restorative care services, specifically passive range of motion (PROM) exercises and the application of a Pressure Relief Ankle Foot Orthosis (PRAFO), were provided to a resident, when in fact these services were not performed. The resident in question had significant cognitive impairment, was unable to make or understand decisions, and had diagnoses including osteoporosis and rheumatoid arthritis, with documented limitations in range of motion. The resident's care plan included physician orders for PROM and PRAFO application five times per week. However, on the date in question, the RNA signed off in the RNA Program Administration Report as if the tasks were completed, despite not having seen the resident or performed the ordered interventions due to insufficient staffing. During interviews, the RNA admitted to signing off on the tasks without performing them and acknowledged that the documentation should have reflected the missed care and the reason for it. The Director of Staff Development confirmed that documentation should always be accurate and never indicate that care was provided when it was not. The facility's policy and procedures also required that documentation in the medical record be objective, complete, and accurate. This inaccurate documentation practice was identified through record review and staff interviews.