Incomplete Documentation of Support Visits After Alleged Mistreatment
Penalty
Summary
The facility failed to ensure that the medical record for a resident with severe cognitive impairment and a history of traumatic brain injury was complete and accurate following an allegation of mistreatment. After a nurse aide reported hearing another aide threaten to withhold feeding from the resident, an investigation was initiated. However, documentation of support visits by social services and nursing staff was either missing or incomplete in the resident's medical record. Specifically, there were no records of social service or nursing support visits prior to a psychiatric provider note made seven days after the incident. Further review revealed that the social worker did not document a support visit in the electronic medical record (EMR), instead placing an undated, unsigned, and unnamed note in the paper chart. The Director of Nursing (DNS) also assessed the resident after the allegation but did not document this assessment in the EMR. Facility policy required licensed nursing personnel to document care and assessments in the resident's medical record, and any paper documentation was to include the resident's name, date, and staff signature. These documentation failures resulted in an incomplete and inaccurate medical record for the resident following the abuse allegation.