Incomplete Documentation of JP Drain Monitoring in Clinical Record
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurate clinical records for a resident with a physician’s order to monitor a Jackson Pratt (JP) drain every shift starting on 11/22/25. Review of the resident’s clinical record confirmed the standing order to monitor the JP drain each shift for prophylaxis. However, review of the Treatment Administration Record (TAR) for December showed missing documentation of the ordered JP drain monitoring on the 3 p.m. to 11 p.m. shift for 12/30/25, and on the 11 p.m. to 7 a.m. shifts for 12/1/25, 12/3/25, 12/10/25, 12/14/25, 12/15/25, 12/16/25, and 12/22/25. These gaps in the TAR indicate that the required monitoring was not documented as completed on multiple shifts. In an interview on 1/6/25 at 1:48 p.m. with the Director of Nursing Services and two surveyors present, the missing documentation findings were confirmed. The incomplete TAR entries for the JP drain monitoring demonstrate that the facility did not ensure the resident’s clinical record was complete and accurate in accordance with accepted professional standards, as required for safeguarding and maintaining resident-identifiable medical records.
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