Incomplete and Inaccurate Clinical Documentation for Insulin Administration and ADL Assistance
Penalty
Summary
The facility failed to maintain complete and accurate medical records for multiple residents. For a resident with diabetes admitted in January 2025, the Diabetic Administration Record (DAR) for December 2025 directed staff to administer insulin before meals. However, at the 5:30 PM administration time there were 4 of 31 instances with no documentation indicating whether insulin was administered or refused, at the 5:00 PM administration time there were 4 of 31 instances with no documentation, and at the 8:00 PM administration time there was 1 of 31 instance with no documentation. An LPN reported that this resident would refuse insulin and ask for it later, then refuse again when it was offered, and acknowledged she forgot to document the refusals on the DAR. The DNS stated the expectation that staff document residents’ refusals on the DAR. For a resident with traumatic brain injury and dementia admitted in January 2025, a quarterly MDS in June 2025 indicated the resident was rarely understood and dependent on staff for eating, and a care plan revised in December 2024 documented total dependence on one staff for eating. Despite this, an August 2025 Documentation Survey Report showed that out of 124 opportunities, staff documented the resident as independent with eating on ten occasions and as requiring setup or clean-up assistance on four occasions. A CNA stated she should not have documented the resident as independent because the resident had always been dependent and required staff support with eating. For another resident admitted in October 2025 with muscle weakness, lack of coordination, and Alzheimer’s disease, an admission MDS indicated significant cognitive issues and a need for substantial to maximal assistance with dressing, and a care plan dated October 15, 2025 documented substantial to maximal assistance of one staff for lower-body dressing. However, a November 2025 Documentation Survey Report showed that out of 61 opportunities, staff documented this resident as independent with lower-body dressing on three occasions. A CNA stated the charting used to be unclear and that she probably missed documenting the resident’s lower-body dressing abilities. The DNS stated she expected accurate documentation of residents’ eating and dressing assistance needs.
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