Inaccurate documentation of a resident fall: A resident on the memory care unit had a fall that was documented as witnessed while walking to the bathroom with a CNA, but the CNA later stated he was caring for the roommate in the bathroom and did not witness the fall. The DON confirmed the discrepancy, and the Administrator said the initial IDPH report was based on the inaccurate progress note. The facility policy required accurate nurses’ notes.
Incomplete and Inaccurate Resident Medical Records: The facility failed to keep accurate clinical records for multiple residents. A resident’s bruise was documented inconsistently, with an RN denying she witnessed the injury and no complete skin assessment or monitoring documented. Another resident’s elopement event was not entered into the medical record, and Wanderguard checks were missed or recorded on the wrong ankle. A third resident’s Wanderguard was documented for the left ankle but was observed on the right ankle.
Inaccurate resident record documentation was identified for a resident whose chart stated that the Medical Director and another physician assessed the resident and imaging, including findings about a possible rib fracture and no pain with PROM. Interviews showed the Medical Director only reviewed radiographs and did not physically assess the resident, and the other physician stated he was asked to review the x-rays, was not the resident’s provider, and did not physically assess her.
Inaccurate behavioral documentation was found for three residents with behavioral health needs. One resident’s records did not reflect a reported verbal incident involving another resident, while two other residents had nurse notes and witness statements describing yelling, verbal aggression, and a verbal altercation that were not captured on the behavioral tracking sheets. The DON and Administrator stated behavior tracking must be completed every shift and that staff were being educated to ensure accurate documentation.
Failure to document frequent seizures and PRN anticonvulsant use: A resident with epilepsy reported having seizures all the time, and staff said seizures occurred almost every day or every other day. An LPN said Valtoco was used during seizures, but the MARs did not document administration, the progress notes had no seizure documentation, and the controlled drug record showed doses were given without corresponding charting.
A resident with multiple chronic diagnoses developed an itchy, scattered rash that was documented in nursing notes and wound records, but the chart did not consistently reflect the dermatology diagnosis. The dermatologist assessed scabies and ordered permethrin and ivermectin, yet a progress note was edited from scabies to skin rash. Staff interviews showed the RN had originally documented scabies but was told by the DON and ADON to change it, and the DON acknowledged documentation problems and said staff were looking for symptoms for the charting.
A resident admitted after hospitalization for RLE cellulitis and an abscess following a fall had conflicting admission dates in the census and MDS, inaccurate fall history and BIMS documentation, and missing admission documentation. Staff confirmed the hospital paperwork was not obtained on the actual admission date, the admission assessment was not completed then, and there was no documentation that the physician was notified or that hospital discharge orders were entered into the EMR and sent to the pharmacy.
Inaccurate documentation of protective sleeve refusal. A resident with an order to wear protective arm sleeves while up in a wheelchair was observed multiple times without them, and the resident said staff did not offer the sleeves. However, the TAR documented the sleeves as applied every day, and the care plan did not include the intervention. The DON stated the sleeves are meant to prevent skin tears and abrasions and that staff should not sign them off if the resident is refusing.
Inaccurate Documentation of ROM Services: Three residents had physician orders for active or passive ROM, but each stated the exercises were not provided and had not been received since admission. Despite this, the Nursing Rehab Time Log documented ROM as completed by CNAs, including entries on the survey date. A CNA said she had not performed the ROM and thought dressing residents counted as ROM, while the Administrator stated documenting care not performed is falsification of documentation.
Untimely post-fall charting and neurocheck documentation left a resident’s record inaccurate and not readily accessible for days after a fall. The resident, who had dementia and multiple medical conditions, fell from a wheelchair, struck the head, was sent to the ED, and later returned with a head hematoma and R humerus fracture. Survey review found several neurocheck and post-fall entries were signed late, including after the resident had died, and one day of post-fall charting was missing. The DON stated the facility standard was to chart as you go, and the HS/Falls Nurse acknowledged the last neurocheck due at 10:00 AM was not completed.
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