Incomplete and Delayed Clinical Documentation by NAC Staff and Social Services
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete, accurate, and accessible clinical records in accordance with professional standards for multiple residents. For one resident, review of December, January, and February documentation reports showed numerous missing Nursing Assistant Certified (NAC) entries in the electronic medical record (Point Click Care) for tasks such as “all care provided,” skin observations, behavioral symptoms, bowel monitoring, ADLs (including dressing, transfers, hygiene, toileting, bathing, bed mobility, continence, walking, and eating), and food and fluid intake across multiple dates and shifts. This resident’s fall risk assessment, dated in February, was also not locked/completed until several days after the assessment date. Another resident’s December and January documentation reports showed multiple days and shifts with no intervention/task documentation by NAC staff. Additional record review showed that three other residents had incomplete or delayed documentation of interdisciplinary care conferences in their electronic medical records. For one resident, the care conference held in February had not been completed by the Social Services Director as of the survey date. For two other residents, care conference documentation was not completed until several days after the conferences occurred. In interviews, NAC staff stated that all NAC documentation was entered into Point Click Care, and leadership staff stated that the expectation was for NAC documentation to be completed by the end of each shift and for care plan conference assessments to be completed/locked within a day of the conference. The surveyors concluded that clinical records were not maintained in accordance with accepted professional standards, placing residents at risk for unmet care needs and diminished quality of life.
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.