Failure to Document Care and Services per Professional Standards
Penalty
Summary
The facility failed to ensure that staff consistently documented care and services provided to residents in accordance with professional standards, as required by the Nurse Practice Act and facility policy. Specifically, for two of three residents reviewed for accident/incident, there were significant gaps in documentation related to behavior monitoring and implementation of care plan interventions. For one resident with Alzheimer's disease, dementia, and diabetes, the care plan required monitoring for wandering behaviors and safety rounds every two hours. However, electronic documentation revealed numerous shifts with missing entries for behavior monitoring, and the Assistant Director of Nursing (ADON) confirmed that the required two-hour monitoring was not documented anywhere. Another resident, admitted with dementia and behavioral disturbances, was identified as high risk for falls and required two-hour rounding at night and toileting assistance prior to bed. Review of the electronic documentation system showed multiple shifts with missing entries for bowel and bladder elimination monitoring, as well as behavior monitoring. The ADON acknowledged that there was no documentation to support that the individualized care plan interventions were implemented for this resident. The facility's own policy required documentation of all pertinent psychosocial, medical, and nursing observations, including the plan of care and resident response. Despite this, the survey found repeated instances where required documentation was missing, and facility leadership could not provide evidence that care plan interventions were carried out as documented. This failure to maintain complete and accurate records constituted a deficiency in meeting professional standards of quality.