Incomplete Capacity Certifications and Inaccurate Pain and Injury Documentation
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurate medical records in accordance with accepted professional standards for two residents. For one resident, review of the medical record showed two “Physician’s Certifications Related to Medical Condition, Decision Making, and Treatment Limitations” forms. Although both forms were signed and dated, the section titled “Certification Regarding Decision Making Capacity” was left blank on each form. The provider did not check either box to indicate whether the resident had adequate decision-making capacity or lacked adequate decision-making capacity, including for life-sustaining treatments. During an interview and dual review of the forms, the Regional Director of Clinical Services confirmed that the forms were not completed and acknowledged that it was the facility’s expectation that the physician check one of the boxes. The date on one form, completed by the Medical Director, was also illegible and not easy to decipher. For the second resident, the deficiency centers on inaccurate and inconsistent documentation related to an injury and pain assessment. A facility-reported incident described a GNA calling the assigned nurse to the resident’s room for a laceration to the right pinky finger with bright red blood and swelling. However, a progress note by a physician assistant from a video visit documented the resident as presenting with a laceration to the left leg with bone exposure and active bleeding, and further described the left fifth digit with bone exposure at the base. The resident had a history of vascular dementia and was a poor historian due to cognitive impairment. Review of a Pain Observation Tool for the same date showed that an RN documented “No” to the question asking whether the resident verbalized and/or exhibited non-verbal symptoms of pain, despite the physician assistant’s note stating the resident was experiencing pain and the wound was actively bleeding. Additional review of the Pain Observation Tool revealed further inaccuracies in medication documentation. In the section on pain relief, the RN documented that the resident received scheduled pain medication (“Yes”) and did not receive PRN pain medication (“No”). A dual review of the December medication administration record showed the resident did not have an order for scheduled pain medication but did have an order for PRN acetaminophen 325 mg, two tablets by mouth every six hours as needed for pain or fever, with a maximum daily dose specified. The DON confirmed that this documentation was not accurate. The DON also stated that the resident only had a laceration to the right pinky finger, and a hospital discharge summary verified that the resident was seen for a laceration to the right pinky, further demonstrating discrepancies between the medical record entries and the resident’s actual condition.
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