Failure to Maintain Accurate Visitor Logs and G-Tube Documentation
Penalty
Summary
Facility staff failed to safeguard resident-identifiable information and maintain accurate records by not ensuring the integrity and retention of the visitor logbook for one resident. A resident admitted with diabetes mellitus, myocardial infarction, fluid overload, hypertension, osteoarthritis, and congestive heart failure reported that $200 was missing from his room while residing on the 2 South unit. The resident stated that his cousin had visited and given him the money. When surveyors reviewed the 2 South visitor logbook for the period when the money was allegedly brought in, they found that pages covering dates from 04/01/2025 through 04/29/2025 were missing. Staff assigned to the resident on the date the money was reported missing stated they were unaware the resident had $200 and described that the process for securing resident valuables would be to notify the RN to place valuables in a safe. The Director of Nursing acknowledged that the visitor logbook was missing pages for that period and that she was unable to locate them. Facility staff also failed to maintain complete and accurate medical records for another resident with multiple diagnoses including stroke, dysphagia, gastrostomy tube, dementia, and seizure disorder. An Annual MDS documented that this resident had a severely impaired BIMS score, was totally dependent on staff for all ADLs and transfers, and had a G-tube for feedings. Physician orders directed that the G-tube site dressing be changed every night shift in the morning and that the enteral feed flush syringe be changed every morning every 24 hours. Review of the Treatment Administration Record for February showed no documented evidence that the G-tube site dressing change was completed on a specified morning as ordered, and review of the Medication Administration Record for the same month showed no documented evidence that the G-tube flush syringe was changed on another specified morning as ordered. The Director of Nursing acknowledged the lack of documentation and stated she could not vouch for what was not done and could only provide education on proper documentation.
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