F0842

D

Inaccurate Clinical Documentation for Weights, MAR, and Skilled Nursing Assessments

Manahawkin, New Jersey Survey Completed on 03-03-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to maintain accurate medical records in accordance with its own policies and accepted professional standards. For one resident, weight documentation showed a drop from 166.5 pounds on 11/28/25 to 150 pounds on 11/29/25. Staff interviews revealed that CNAs are responsible for obtaining weights and are expected to reweigh residents if there is more than a 2‑pound change and notify the nurse for significant changes. The PACU Unit Manager stated that a 15‑pound weight loss should prompt notification of the physician and nutrition, and the nutritionist reported that a 15‑pound loss typically triggers a weight alert and re‑weigh request. When shown the weight entries, the Unit Manager stated she was unsure what happened and believed it was probably an error, and the DON acknowledged that the facility’s weight policy, which requires re‑weighing if a weight is not as expected, was not followed and that the 11/29/25 weight was likely a mistake.

A second component of the deficiency involved incomplete medication administration documentation for another resident. Review of the February 2026 MAR showed a blank entry for an oxycodone dose on 2/14/26. An LPN stated that medications are to be signed out on the MAR in real time as they are administered, and the PACU Unit Manager stated she expects all staff to complete required documentation, including MARs. The DON stated that staff are well educated and trained in documentation and facility policies, yet the MAR review showed that the oxycodone entry was not signed out as required, resulting in an inaccurate medication record.

The third component involved inaccurate nursing documentation in the Nursing Advanced Skilled Evaluations for another resident. Review of these evaluations showed that three nurses clicked the wrong button under the Nutrition section, creating documentation errors. The LPN interviewed confirmed that this documentation serves as an attestation for a daily head‑to‑toe assessment. The PACU Unit Manager and the DON both confirmed that a new assessment is expected each shift and that staff must pay attention to what they document because it is their attestation. The surveyor pointed out that under Nutrition, nurses were selecting “met” for an item asking if the resident was taking nutrition and hydration orally, had no complaints of thirst, no signs or symptoms of a swallowing disorder, and moist mucous membranes, and the DON acknowledged the error and stated she could see how this could be confusing for staff. The surveyor also noted that three nurses made this documentation error while other nurses did not, despite facility policies requiring documentation to be factual, objective, clear, pertinent, and accurate.