Failure to Provide and Document Required Care and Treatment
Penalty
Summary
Two residents were identified as not receiving treatment and care in accordance with professional standards of practice. One resident, who had diagnoses including dementia, multiple sclerosis, and peripheral artery disease, was bedridden and had severe cognitive and physical impairments. This resident had a physician's order for daily wound care to the left below the knee area, including cleansing and application of topical ointment with a silicone dressing. Review of the treatment administration record for March 2025 showed that the treatment was not signed as completed by the LPN on three separate days. There was no documentation explaining the missed treatments or any notification to the physician regarding these omissions. During interviews, the LPN stated they may have forgotten to document the treatment in the electronic medical record, but could not confirm whether the treatment was actually completed or not. Another resident, with a history of schizophrenia, dysphagia, and constipation, was also found to have deficiencies in care. This resident was at high risk for constipation and required regular monitoring and documentation of bowel movements by certified nurse aides (CNAs) every shift, as outlined in the care plan. However, review of CNA accountability records for February and March 2025 revealed numerous omissions in documentation regarding the resident's bowel movement activity. In February, there were 25 occasions without documentation, and in March, 19 occasions were noted. Interviews with CNAs and the DON confirmed that documentation was expected to be completed every shift, and that blank boxes indicated either an omission or oversight. The facility's policy required accurate, timely, and complete documentation by CNAs in the electronic medical record to support high-quality resident care. The DON stated that nurses and supervisors were responsible for checking and ensuring documentation was completed, and that reports of undocumented tasks were distributed to unit managers for follow-up. Despite these processes, the records showed repeated failures to document required care and monitoring for both residents, with no evidence that omissions were addressed or communicated as required.