Staff failed to document required nursing care and treatments for two residents, resulting in incomplete medical records. One resident with dementia, Parkinson's disease, and severe malnutrition had a standing order for aspiration precautions every shift, but the TAR lacked documentation that these precautions were provided on two shifts. Another resident with respiratory and pain-related diagnoses had orders for non-skid socks during the evening shift for fall risk and for heel elevation/floating on pillows for pressure relief every shift while in bed, yet the TAR showed no evidence these interventions were documented on multiple evening shifts. A CNM acknowledged the missing documentation and uncertainty about whether chart checks include verifying completion of ordered care.
A resident with epilepsy and intact cognition had a physician order for Lacosamide 200 mg BID for seizure precaution. The controlled drug record showed the last available dose was given on one evening, with zero tablets remaining thereafter, while the MAR reflected that an LPN documented additional nighttime doses on three later dates. Review of Omnicell inventory showed Lacosamide tablets in stock but no documentation that any were removed or delivered to match the charted administrations. A facility-reported incident confirmed that the resident did not receive the doses that had been signed out by the LPN, indicating false documentation of medication administration.
Two residents were affected by failures in record accuracy and retention. One resident, with multiple cardiac and chronic conditions, reported missing cash that had been given by a cousin, but review of the unit visitor log showed missing pages for the relevant period, and staff reported they were unaware of the money and described a process for securing valuables that was not documented as used. Another resident, dependent for all ADLs with a G-tube, had physician orders for routine G-tube site dressing changes and daily flush syringe changes, yet the TAR and MAR lacked documentation that a scheduled dressing change and a scheduled flush syringe change were completed as ordered; the DON acknowledged the missing documentation.
Staff inaccurately documented that two residents received scheduled showers with skin checks when, according to the residents and the assigned RN, they had refused showers and instead received bed baths. Documentation on the TAR and CNA records showed showers as completed and refusals recorded, despite residents’ statements that no showers occurred. In a separate case, a resident with COPD and chronic respiratory failure, who had active orders and care plan interventions for continuous O2 via nasal cannula and was coded on the MDS as using oxygen therapy, was documented on a Safe Smoker Assessment as having no continuous or PRN oxygen order and as a safe smoker who preferred cigarettes, even though the resident reported not having smoked for many years.
Failure to document powered wheelchair education for a resident. A resident with morbid obesity, bilateral LE lymphedema, and muscle weakness received a powered wheelchair, but the chart lacked evidence that staff documented receipt of the equipment or education on safe use. Although the resident and an RN/unit manager stated education was provided, the record did not show when the wheelchair was delivered or that the teaching was documented.
Inaccurate documentation of scheduled bathing care was found for a resident who was dependent on staff for ADLs and ordered to receive showers twice weekly. The resident was listed on the shower log and the TAR was signed as if care had been provided, but the resident stated staff never offered a shower and the assigned RN later said the resident actually refused and that the refusal was not documented. The DON acknowledged the findings.
Inaccurate resident record documentation was found for two residents. One resident with dysphagia and tube feeding orders had charting that repeatedly identified a G-tube, although the RN/Unit Manager stated the resident actually had a J-tube. Another resident with dementia had charting that described a bruise on the right cheek, while staff stated the bruise was above the right eyebrow and other notes referenced the right forehead/right eye area.
A resident with severe cognitive impairment and depression was prescribed Trazodone 50 mg at bedtime, but only 25 mg half-tablets were available for administration. Staff documented giving the full 50 mg dose on the MAR, but it could not be confirmed whether the correct amount was actually administered, as only half-tablets were present and staff could not verify the dosing process.
A resident with dysphagia and other complex medical needs had inconsistent and incorrect information documented in speech-language pathology treatment notes and the care plan. The SLP's notes did not match the physician's diet order or the dietary records, and the care plan inaccurately described the resident's eating habits. Staff interviews confirmed the documentation errors and clarified the resident's actual dietary needs and preferences.
Staff documented the administration of medications, treatments, and vital signs for a resident who had already been transferred to the hospital due to chronic respiratory failure and related conditions. This resulted in inaccurate medical records, as confirmed by staff interviews and record review.
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