Failure to Document Overnight Care for Multiple Residents
Penalty
Summary
The facility failed to ensure accurate and complete documentation of care provided to four residents during the overnight shift from 10:00 p.m. to 6:00 a.m. on the dates reviewed. For one resident who was on hospice care and found deceased around 6:00 a.m., there was no documentation of care provided during the night, nor any record of a change in condition that would have required intervention. The resident's care plan required two CNAs for bed mobility and mechanical lift transfers, and staff were expected to provide incontinent care and repositioning at least every two hours. However, the resident's progress notes, medication administration records, and point-of-care documentation lacked entries for the entire overnight period, except for a single set of vital signs recorded at 1:27 a.m. The postmortem assessment indicated the resident was found unresponsive, cold to the touch, and with fixed and dilated pupils, with no evidence of care or monitoring during the preceding shift. Similarly, three other residents, all with significant cognitive and physical impairments and dependent on staff for all activities of daily living, had no documentation of care provided during the same overnight shift. Their care plans also required frequent assistance, including turning, repositioning, and incontinent care at least every two hours. Review of their point-of-care records revealed no entries for any care activities during the specified time frame. Staff interviews confirmed that CNAs and nurses were responsible for providing and documenting care at least every two hours, and that documentation was expected to be completed in the electronic health record after each task. Interviews with staff, including CNAs, nurses, the ADON, and the medical director, revealed inconsistent understanding of the facility's expectations for resident checks and documentation frequency. While some staff stated that care should be provided and documented every two hours, others were unclear about the specific requirements. The facility lacked a formal policy on rounding or checking on residents, and the documentation policy emphasized the need for timely, accurate, and complete entries in the clinical record. Despite these expectations, the absence of documentation for multiple residents during the overnight shift indicated a failure to maintain accurate medical records in accordance with professional standards.