Incomplete and Inaccurate Documentation of Pacemaker Monitoring and Urinalysis Results
Penalty
Summary
The deficiency involves incomplete and inaccurate clinical records for a resident related to pacemaker monitoring and urinalysis documentation. On review of the February Treatment Administration Record (TAR), the order to check that the resident’s pacemaker monitor was plugged in once per evening shift was documented on two dates with staff initials and a code of “2,” indicating “drug not available,” which was not appropriate for this type of treatment. During interview, the RN who documented these entries acknowledged that both entries were incorrect and could not explain why the “drug not available” code was used for the pacemaker monitor check, and the surveyor confirmed this inaccurate documentation. Additionally, the TAR contained an order for a surveillance urinalysis (UA) dip with instructions to follow up with a culture if positive to ensure a urinary tract infection was resolved. The TAR showed staff initials indicating the UA dip was performed on one date, but the clinical record and the corresponding physician order lacked any evidence of the UA dip result. In an interview, the Skilled Unit Manager reported that the RN who performed the treatment stated he completed the UA dip but did not chart the result because nothing appeared in the system for him to document after signing off the treatment, nor did he print and file the machine-generated results with the physician order. The surveyor confirmed the absence of documentation for the UA dip result in the record.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.