Incomplete Documentation of Treatments and Medications
Penalty
Summary
The facility failed to maintain complete and accurate clinical records in accordance with accepted professional standards for three residents. For one resident with a history of diabetes, COPD, and pressure injuries, the Treatment Administration Record (TAR) for March was found to have multiple unsigned sections for physician-ordered treatments, including wound care and use of a pressure-reducing mattress. Nursing staff interviewed confirmed they had provided the treatments but did not sign off on the TAR, citing reasons such as forgetting due to being busy or not understanding the significance of blank entries. Staff acknowledged that they had received training on documentation requirements but did not consistently follow facility policy. Another resident with diagnoses including diabetes, heart failure, and skin integrity issues had incomplete documentation on both the TAR and Medication Administration Record (MAR). Several physician-ordered treatments for wounds and pressure reduction were not signed off on the TAR for various shifts, and a blood sugar check and insulin administration were not documented on the MAR. Nursing staff responsible for these omissions stated they either forgot to document, did not see the order, or were unsure of the policy. In one instance, a nurse failed to document a resident's refusal of a blood sugar check and insulin, which should have been coded appropriately on the MAR. A third resident, also with diabetes and severe cognitive impairment, had incomplete documentation on the MAR for sliding scale insulin orders. The MAR lacked signatures and blood glucose documentation for scheduled times, and staff could not recall the specifics of care provided on those dates. Interviews with nursing and administrative staff confirmed that the required documentation was missing and that staff had not followed the facility's documentation policy, despite recent training. The facility's policy requires all assessments, observations, and services to be accurately and timely documented in the resident's medical record, which was not adhered to in these cases.