Failure to Provide Agency CNA Access to Electronic Documentation System
Penalty
Summary
The facility failed to maintain complete and accurate clinical records for a resident who required transfer assistance, as required by accepted professional standards. Specifically, a contracted agency CNA was not given access to the electronic documentation system (Kiosk) to record the care provided to assigned residents in one of the facility's halls. As a result, the care delivered during the shift was not directly documented by the CNA who provided it, but instead was entered by another CNA who worked alongside him. This documentation was recorded under the second CNA's name after she verbally collected information from the agency CNA at the end of the shift. The resident involved had a complex medical history, including diabetes mellitus, osteoarthritis, rheumatoid arthritis, pemphigus vulgaris, and Stevens-Johnson syndrome, with multiple skin lesions and impaired activities of daily living. The resident was severely cognitively impaired, dependent on staff for most activities, and had ongoing issues such as chronic pain, incontinence, and pressure ulcers. The care plan required regular assessments and documentation of care, including wound care and assistance with activities of daily living. Interviews with facility staff and the agency CNA revealed that the CNA was not provided with access to the electronic record system because the Director of Nursing was unaware that he had been scheduled to work that shift. The agency CNA was not given instructions or assistance to document care, and the agency's scheduling coordinator confirmed that agency staff are typically given access to chart before their shifts. The lack of direct documentation by the assigned CNA resulted in incomplete and inaccurate clinical records for the resident.