Incomplete Medical Records and Inaccurate Care Plans Identified
Penalty
Summary
The facility failed to maintain complete and accurate medical records for two residents, as evidenced by missing documentation in the Certified Nursing Aide (CNA) accountability logs and care plans that were not updated to reflect current resident needs. For one resident with moderate cognitive impairment and incontinence, the CNA documentation logs for activities of daily living (ADLs) had multiple blank entries for specific dates in October, despite the expectation that CNAs document every shift. The Director of Nursing (DON) confirmed that the ADL log was the required care log for CNAs and acknowledged the missing documentation when notified by surveyors. For another resident with a history of stroke, hemiplegia, and urinary incontinence, the care plan was not revised to accurately reflect the resident's incontinence status and preference for extra protection until after surveyor inquiry. The CNA documentation for this resident also had blank entries for several shifts in October. Additionally, the resident was observed wearing double incontinent briefs, a preference that was only added to the care plan on the day of the survey after being brought to the attention of the DON. The DON confirmed that the care plan had not been updated to reflect the resident's current needs prior to the surveyor's inquiry.