Incomplete and Inaccurate Documentation of Resident Services
Penalty
Summary
The facility failed to ensure that a resident's clinical record contained complete and accurate documentation of services not received, as required by its own policy and procedure on charting and documentation. Specifically, a resident with a history of traumatic brain injury, tracheostomy, ventilator dependence, and gastrostomy had physician orders for Restorative Nursing Assistant (RNA) program interventions, including the application of bilateral resting hand splints and bilateral knee extension splints. Documentation indicated that the resident received and tolerated these splints for specified periods; however, interviews and record reviews revealed that the resident was unable to tolerate the splints during certain dates, and this was not accurately documented in the medical record. RNA staff acknowledged that they did not write progress notes to reflect the resident's inability to tolerate the splints, despite being aware of the issue and notifying the Director of Rehabilitative Services (DOR) during an RNA meeting. The DOR confirmed that documentation should have accurately reflected the services provided and the resident's tolerance, and that oversight of RNA services and documentation accuracy was their responsibility. The facility's policy required objective, complete, and accurate documentation of treatments and resident tolerance, which was not followed in this instance.