Inaccurate and Late Documentation of Treatments and Skin Procedures
Penalty
Summary
The deficiency involves failures in maintaining complete, accurate, and professionally acceptable medical records for multiple residents. For one resident with diagnoses including dermatitis, type 2 diabetes mellitus, and Parkinson's disease, the facility admitted the resident in December 2024 and later readmitted them. The resident’s MDS dated early December 2025 showed severely impaired cognitive skills for daily decision making. Physician orders dated January 9, 2026, directed application of clotrimazole-betamethasone cream twice daily for unspecified dermatitis. A Change of Condition Interact Assessment Form dated January 16, 2026, showed the resident was transferred to a general acute care hospital on that date. However, the Treatment Administration Record (TAR) for January 2026 contained the treatment nurse’s initials on January 17, 2026, as if care had been provided while the resident was already hospitalized. The treatment nurse stated she forgot to change the chart code to hospitalized and acknowledged the documentation was not accurate. Another deficiency involved inaccurate and incomplete documentation of a second resident’s skin condition and related procedures. This resident, admitted in January 2023 with diagnoses including cerebral infarction, muscle weakness, and essential hypertension, had an MDS indicating moderately impaired cognitive skills for daily decision making. A clinical admission assessment dated December 25, 2025, documented the resident’s skin as warm, dry, with normal color and turgor and no skin issues. However, a skin reassessment dated December 26, 2025, documented rashes on bilateral lower and upper extremities, chest, and back. Physician orders dated January 26, 2026, directed a STAT skin scraping for unspecified dermatitis. The TAR for January 2026 initially showed no licensed nurse initials or time for the STAT skin scrape. A treatment nurse later stated he had only observed another treatment nurse perform the skin scraping, signed the TAR two days after the procedure, did not remember the actual time, and guessed the time for this and other residents’ procedures. The nurse who actually performed the skin scraping confirmed she did not document the procedure in the TAR and that the documentation was not timely or accurate. Similar documentation issues occurred for two additional residents with cognitive impairment and multiple medical diagnoses, including unspecified dementia, essential hypertension, age-related osteoporosis, and metabolic encephalopathy. For both residents, physician orders dated January 26, 2026, directed STAT skin scrapings for unspecified dermatitis. Their TARs for January 2026, when first printed, showed no licensed nurse initials or times for the ordered STAT skin scrapings. The observing treatment nurse later reported he had been watching another treatment nurse perform the procedures because he had not done skin scrapings before, and he signed both residents’ TARs two days after the procedures. He stated he did not remember the actual times and guessed the times, documenting the same time for both residents. The treatment nurse who performed the procedures confirmed she did not document the skin scrapings in the TARs and acknowledged the documentation was not timely or accurate. The Director of Nursing, when reviewing these records, stated that the documentation for all involved residents was not accurate and that the facility failed to follow its own charting and documentation policies, which require objective, complete, and accurate documentation of treatments, including date, time, and the name and title of the individual providing care.
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