Inaccurate Documentation of Resident Care and Rounding After Resident Death
Penalty
Summary
The facility failed to maintain accurate and professional documentation of medical records for one resident reviewed for activities of daily living (ADL) care. Specifically, a Certified Nurse Aide (CNA) was documented in the electronic medical record as having provided ADL care to a resident on a certain date, but the CNA stated during interview that they did not provide care to the resident on that date, nor did they enter the documentation. The CNA also indicated that the resident's name was not on their assignment sheet. The facility's Director of Nursing confirmed that CNAs are instructed not to share their passwords and that documentation should only be completed by the assigned CNA using their unique credentials. Additionally, a Licensed Practical Nurse (LPN) documented hourly rounding for the same resident from late evening through early morning, including times after the resident had expired and their remains had been removed from the facility. The LPN stated that documentation was started later in the shift due to an incident and police presence, and acknowledged that the resident's name should have been removed from the rounding sheet after death. The Director of Nursing confirmed that the resident was removed from the unit by the Medical Examiner and was unable to explain why documentation continued after the resident's removal. These actions resulted in inaccurate and incomplete medical records, not in accordance with accepted professional standards.