Incomplete ADL Documentation for a Dependent Resident: A resident who was dependent on staff for toileting transfers, hygiene, and mobility had multiple missing CNA ADL entries across day, evening, and night shifts. Facility policy required CNA documentation each shift, and both a CNA and the DON stated ADL care should be documented before the end of the shift, but the record lacked evidence of toileting and hygiene assistance on numerous occasions.
A resident with dementia was care planned for partial assist with dressing, but the record did not accurately reflect the care provided. The resident’s son reported the resident wore the same soiled clothes for days, and surveyors observed the resident in the same outfit on consecutive days. Dressing task documentation showed no evidence of clothing being obtained on one shift and was inconsistent with staff statements that the resident had been assisted and changed.
Incomplete Clinical Records and Missing MAR/TAR Documentation: A resident with an unwitnessed fall had missing neuro checks despite a provider order for monitoring per protocol. Two other residents had numerous MAR/TAR omissions, including missed documentation for VS, wound care, pain assessments, fluid restriction, skin treatments, behavior monitoring, CHF education, weights, and other ordered interventions. The Market Clinical Advisor confirmed the missing documentation during interview.
A resident receiving PT/OT had unsigned PT orders in the clinical record, while another resident with a left lower leg fracture, NWB status, chronic pain, urinary incontinence, and constipation risk had missing bladder and bowel ADL documentation across multiple shifts. The record also showed a gap of over 40 hours between bladder entries.
A resident’s record contained inaccurate hospice documentation. The chart showed the resident had been discharged from hospice, but multiple provider notes later stated the resident was on hospice level care and receiving weekly hospice visits, even though the record lacked evidence of active hospice services. The DON confirmed the notes were not accurate.
Incomplete and inaccurate ADL documentation was found for two residents with toileting assistance needs and incontinence. One resident had missing shift documentation for bladder elimination, toilet transfer, and toileting hygiene, while the other had missing entries for bladder and bowel elimination, toilet transfer, toileting hygiene, scheduled toileting every 2 hours, and a requested 4:00 a.m. bedpan intervention; some entries were also charted at the start of the night shift instead of overnight. The DON confirmed the clinical records were not complete and accurate.
Two residents experienced deficiencies in clinical record documentation when multiple active physician orders for medications, treatments, monitoring, positioning, and meal-related care were not documented as completed on the MAR/TAR, and when a provider progress note contained outdated wound care and foley catheter information that did not match current orders. The DON confirmed that the records lacked evidence of completion for ordered interventions and that the provider note did not accurately reflect the resident’s current wound care regimen.
Incomplete neurological and wound documentation was found for two residents with unwitnessed falls and one resident with a right heel pressure injury. Neuro checks after falls were not fully documented at required intervals, and the wound record lacked staging, measurements, and description while the chart contained conflicting pressure injury stages from the RN, NP, and wound clinic records.
A resident with atrial fibrillation was receiving Eliquis (apixaban) twice daily as ordered, and the MAR showed doses were given as scheduled. Following two separate falls, staff completed SBAR Communication Forms and progress notes to notify the provider of the change in condition. However, on both occasions, the Background section under Medication Alerts on the SBAR forms did not indicate that the resident was on an anticoagulant, despite the form’s directive to complete relevant sections before contacting the MD/NP/PA. During interviews, facility leadership confirmed that the SBAR documentation for these falls failed to reflect the resident’s anticoagulant therapy, resulting in incomplete and inaccurate clinical records.
Incomplete and inaccurate resident records were identified for two residents. One resident’s missing glasses were reported by the resident and roommate, but the chart and CNA documentation still showed the glasses being used daily and did not document the loss or notification of the resident representative. Another resident’s record showed an antipsychotic medication recommendation for a more specific diagnosis, but the diagnosis was updated to behaviors rather than a true clinical diagnosis before later being changed to vascular dementia with behaviors by the provider.
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