Failure to Document Activity Services in Resident Medical Record
Penalty
Summary
The deficiency involves the facility’s failure to maintain accurate clinical records for one resident by not documenting activities and room visits as required by policy and accepted professional standards. The resident was admitted with malignant neoplasm of the ribs, sternum, and clavicle, muscle weakness, and difficulty walking, and had intact cognition per the MDS. The MDS also showed the resident required setup or clean-up assistance with eating and was dependent on staff for oral hygiene, toileting hygiene, and personal hygiene. An activity assessment identified the resident’s preferred activities as exercise/sports, watching TV, music stimulation, book tapes, talking/conversing, and spiritual visits, and indicated that recreation staff provided an activity calendar, informed the resident where recreation materials were available, and discussed which groups he might like to attend. A family member reported that the resident remained in bed in his room all day with no activities. The AD stated that each of the four nursing stations had an activity assistant, that activity staff greet residents daily, review the activity calendar, and conduct room visits for residents who do not attend group activities, and that room visits are to be documented in the facility’s computer system. However, upon review of the resident’s documentation survey report for independent activity and room visits, the AD confirmed there was no documented evidence of room visits by activity staff for this resident from admission through the review period. The AD acknowledged that she conducted room visits on the resident’s unit but did not document the activities provided and stated there was no excuse for not documenting, despite facility policies requiring that health services and progress toward care plan goals, as well as changes in the resident’s condition, be documented in the medical record to facilitate communication among the interdisciplinary team.
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