Failure to Document Resident Repositioning as Required by Care Plan
Penalty
Summary
The facility failed to accurately document the turning and repositioning of a resident whose care plan required repositioning every two hours. The resident, who had multiple complex medical diagnoses including acute and subacute infective endocarditis, pneumonitis, a displaced bicondylar fracture, COPD, dysphagia, and peripheral vascular disease, was care planned to be repositioned at least every two hours to facilitate lung secretion movement and drainage. Despite this, interviews with multiple nursing assistants revealed that while they reported repositioning residents every two hours, they did not document these actions. The registered nurse also confirmed that the facility staff did not document when residents were rounded on or repositioned. Additionally, when the facility's policy for activities of daily living (ADL) documentation was requested, none was provided. The lack of documentation was consistent across all interviewed staff, and there was no evidence in the resident's records to confirm that the required repositioning was performed as per the care plan. This failure to maintain accurate and complete medical records is not in accordance with accepted professional standards.