Failure to Timely Document Resident Refusal and Monitoring
Penalty
Summary
The facility failed to maintain complete and accurate clinical records in accordance with accepted professional standards for one resident. Specifically, there was no timely documentation regarding a resident's refusal to leave the facility's courtyard until 1:00 AM, despite the resident being checked on multiple times by an LVN during the night. The LVN stated that he was informed by the previous shift that the resident was in the courtyard and not ready to return inside, and he continued to check on the resident every 20-30 minutes. However, no progress note was entered into the electronic record at the time of the incident to reflect the resident's actions or the staff's monitoring. The resident involved had multiple diagnoses, including Parkinson's Disease, Type 2 Diabetes, Schizoaffective Disorder, Bipolar Disorder, Anxiety Disorder, chronic pain, visual impairment, hypertension, COPD, and dysphagia, and was assessed as having moderate cognitive impairment. The lack of timely documentation was only addressed days later with a late entry note. The facility's own policy required nursing documentation to be completed by the end of the assigned shift, which was not followed in this instance.