Non-Nursing Staff Documented Clinical Event in Resident Record
Penalty
Summary
The facility failed to follow professional standards of practice in documentation for one resident. A resident with diagnoses of anxiety, muscle weakness, and high blood pressure, and with a severe cognitive impairment, required substantial assistance with toileting and hygiene. The resident experienced a fall while attempting to transfer from the commode to a wheelchair, resulting in a skin tear and headache. The incident was documented as a late entry progress note by the Nursing Home Administrator, who is not a nurse. Interviews with facility staff confirmed that documentation of clinical events should not be completed by non-nursing personnel, and that the Nursing Home Administrator was not authorized to enter such notes. This failure to adhere to professional standards of documentation was identified for one of eight residents reviewed, as supported by facility policy review, resident record review, and staff interviews.