Incomplete Documentation of Falls, Hospice Services, and Anticoagulant Therapy
Penalty
Summary
The facility failed to maintain complete and accurate documentation for two residents regarding falls, hospice services, and anticoagulant therapy. For one resident with Alzheimer's dementia receiving hospice care, there was incomplete documentation following a fall from a Broda chair. Although the care plan identified a risk for falls and interventions were updated, the clinical record lacked documentation of observed injuries, such as bruising around the eye, and did not include required 72-hour follow-up notes. Neurological checks were not performed as scheduled, and hospice progress notes were not available in the resident's record, requiring staff to contact the hospice provider for information. Additionally, an intervention noted by hospice staff was not incorporated into the resident's care plan or observed in practice. For another resident with dementia, heart failure, and a prosthetic heart valve, the facility did not maintain accurate records of PT/INR lab results required for monitoring anticoagulant therapy. The care plan required regular PT/INR testing and prompt reporting of critical results, but the clinical record showed missing or unscheduled lab results and incomplete documentation on the Medication Administration Record (MAR). Facility staff sometimes used a log book at the nurses' station to record PT/INR results, but these logs were not included in the resident's clinical record as required by facility policy. Interviews with staff and administration confirmed that documentation practices did not align with facility policy, which requires all assessments and records from facility staff and contracted professionals to be included in the resident's clinical record. The lack of thorough and timely documentation affected the facility's ability to coordinate care and ensure accurate records for both residents.