Failure to Maintain Accurate Medication, Toileting, and Nutritional Intake Records
Penalty
Summary
The deficiency involves the facility’s failure to maintain accurate and complete medical records for multiple residents. For one resident with morbid obesity, depression, chronic venous stasis, lymphedema, anemia, and pulmonary hypertension, the nurse practitioner ordered Aquaphor to be applied to both lower extremities three times daily. The MAR showed scheduled administration times in the morning, afternoon, and evening. On one review date, the morning Aquaphor dose had not been signed as given, and later that same day the MAR reflected that the afternoon dose had been signed out by an RN. However, direct observation shortly afterward revealed no visible Aquaphor on the resident’s lower legs, and the resident reported that no one had applied it all day. The administrator confirmed there was no Aquaphor visible despite the MAR being signed for that time frame, and the RN acknowledged she had signed for administration before actually applying the medication. Another resident, admitted with heart failure, stroke with right-sided paralysis, cognitive and language deficits, morbid obesity, depression, and bowel and bladder incontinence, had an MDS showing a severely impaired BIMS score and participation in a bladder and bowel incontinence program. The care plan called for a routine bowel and bladder program with staff checking and offering toileting assistance every two hours. Review of the Bladder Program Service Delivery Records for several months showed numerous blanks where staff were to document incontinence checks and toileting assistance, including multiple specific dates in one month with no entries at all. A CNA interview confirmed that CNAs are expected to perform and document two-hourly checks and toileting, that the documentation is kept in a logbook at the nurses’ desk, and that aides, including the interviewed CNA, sometimes forget to sign the logs. A third resident with Alzheimer’s disease, schizoaffective disorder, bipolar disorder, severe protein-calorie malnutrition, anxiety, paranoid schizophrenia, cerebral palsy, and major depressive disorder had a care plan identifying risk for altered nutrition and preferences for sweets, pop, milk, ice cream, pudding, and yogurt, with variable oral intake and acceptance of supplements. The MDS showed severe cognitive impairment and interventions including supplements and menu alternatives. Weight records showed ongoing weight loss, and dietician notes documented significant percentage weight loss over 90 and 180 days, low BMI, variable intake from 1% to 100%, and use of multiple nutritional supplements. Review of meal intake documentation revealed missing entries, including days where only dinner was documented and days with no meal intake documentation at all. The regional dietician consultant and the DON both verified that meal intake documentation for this resident was incomplete or missing in the electronic record.
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