Shared EMR Logins Lead to Incomplete and Non-Identifiable Nursing Documentation
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurate clinical records that identify the individual documenting in the electronic medical record (EMR), contrary to its own Charting and Documentation Policy. For a resident with dementia and severe cognitive impairment who required assistance with ADLs, multiple nursing notes over several days documented pain medication administration, medication tolerance, and absence of pain, but were electronically signed with generic identifiers such as "2LPN pool2 LPN" and "poolnurse supervisor RN" rather than the specific nurse’s name. For a second resident with bipolar disorder, psychotic disorder, anxiety, delusions, and a history of rejecting care, a nursing note describing the resident’s refusal of care and irritable, loud behavior was also signed with a generic “poolnurse supervisor RN” identifier. Additional notes for this resident were similarly signed with “2LPN pool2 LPN,” preventing identification of the specific staff member who provided and documented the care. During interview and record review, the DON confirmed that all agency (pool) RNs, LPNs, and NAs use shared, common logins for EMR access, resulting in documentation that does not display the individual staff member’s name. The DON stated that to determine who wrote a particular nursing note, she would need to cross-reference the facility schedule with the date and shift of the entry. The DON acknowledged that this shared-login practice was long-standing, that notes should include the name of the person writing the note, and that facility policy requires documentation to include the name and title of the individual who provided care and the signature and title of the individual documenting. Despite this, agency staff were not provided with individual EMR logins, leading to incomplete and non-individualized documentation for the residents reviewed for abuse.
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