A resident's meal intake was inaccurately documented in the EMR when a CNA charted 75 to 100 percent consumption of breakfast and lunch despite an observation showing an untouched lunch tray at the bedside. Staff reported that a new CNA on the assignment did not have EMR login access, another CNA charted based on what was reportedly told to them, and the DON was aware of the login issue. The Administrator stated the facility did not maintain a policy for CNA documentation in the EMR.
Failure to document a fall after a resident was lowered to the floor during OT. The resident had MS, a prior tibia/fibula fracture, repeated falls, weakness, reduced mobility, and required extensive assist for transfers. Staff did not complete a timely progress note or initial post-fall assessment, and the DON reportedly told the RN it was not a fall and did not need documentation, despite the facility policy defining an intercepted fall as a fall.
Incomplete and inaccurate documentation was found for two residents. One resident’s narcotic record showed a RN signed another nurse’s name for a Pregabalin dose after the medication had been given, and the other resident’s TARs had multiple missing entries for ordered wound care, foot checks, and offloading/shoe use. The DON acknowledged the missing documentation and stated staff were not completing the TAR entries as expected.
Incomplete documentation after a choking emergency: A resident with anxiety disorder, mild intellectual disabilities, and dysphagia was eating pancakes when she began gasping for air. Staff performed the Heimlich maneuver and suctioned the resident, but the record did not show whether she died in the facility or at the hospital, whether she left with EMS, or any follow-up information or hospital contact. The DON stated documentation should provide a clear picture and a paper trail.
False documentation of blood glucose check and insulin administration: A resident with DM and multiple comorbidities had orders for Accucheck monitoring and sliding scale insulin. An RN documented a blood sugar check and 4 units of insulin as given, but video review did not show the RN obtaining the glucose reading or administering insulin, and no other nurse was found to have done so. The RN stated she signed off the order while finishing documentation even though she knew she had not given the insulin as ordered.
A facility failed to protect resident information when a report sheet with 6 residents’ code statuses and functional abilities was left face-up and visible on a medication cart. An RN stated she normally covers the sheet but responded quickly to an emergent resident call, leaving it exposed, while an LPN and the DON stated resident information should be secured.
Inaccurate MAR documentation showed medications as administered for two residents even though the DON confirmed they were not given during an evening med pass. One resident had cancer, renal insufficiency, and malnutrition with no cognitive impairment, while the other had a blood clot, depression, and dementia with severe cognitive impairment. Staff found bubble packs with crushing envelopes still attached, and an LPN had signed the MAR as if the meds were given.
Two residents had inaccurate clinical records. One resident’s chart contained multiple weight entries that were later struck out, with conflicting MDS, progress note, and care plan documentation about weight loss versus weight gain; staff could not explain why the weights were removed. Another resident had an ARNP note documenting a routine face-to-face exam and complete assessment even though the resident was in the hospital, not in the facility, creating a record that did not match the resident’s actual location and condition.
Incomplete Documentation of Injuries of Unknown Origin: The facility failed to maintain complete clinical records for two residents with bruising of unknown origin. One resident with severe dementia and anticoagulant use had a documented bruise on the wrist, but the record lacked documentation of the incident. Another resident with severe memory and decision-making impairment, hallucinations, and anticoagulant use had bruising under the eye with pain, but the record lacked documentation of the injury investigation. The DON confirmed the missing documentation.
Inaccurate documentation of resident care tasks occurred when the ADON charted follow-up reports for CNAs without confirming the care was actually completed. Records showed the ADON documented toilet transfer, toileting hygiene, and upper body dressing tasks for multiple residents with cognitive impairment, including residents with dementia, severe cognitive impairment, arthritis, hip fracture, legal blindness, urinary incontinence, and intellectual disabilities. Interviews confirmed staff were expected to chart their own care, but the ADON often charted for them and did not know for certain the tasks had been done.
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