Incomplete and inaccurate resident clinical documentation: Records for multiple residents contained conflicting or missing information about unwitnessed falls, neuro checks, transfer times, vital signs, POLST forms, meds, treatments, bed hold notices, and meal intake. For one resident with repeated falls, the chart did not clearly show the sequence of events or complete post-fall neuro monitoring, while another resident’s transfer documentation included delayed and inconsistent vital signs and conflicting POLST forms. Other records lacked treatment documentation and meal intake entries for residents with weight loss.
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's profile was not updated to reflect a responsible party, even though the resident was not capable of completing an Advance Directive and a family member had agreed to make decisions on the resident's behalf. The surveyor also could not locate an Advance Directive in the clinical record, and the Administrator confirmed the facesheet still listed the resident as responsible for self.
A resident with ESRD and dependence on HD had incomplete clinical documentation related to dialysis care. The chart lacked evidence of dialysis and left arm fistula monitoring orders for part of the stay, the TAR did not show fistula monitoring, and the record did not show completion of the required Pre/Post Dialysis Evaluation. An RN said she checked VS and access after dialysis but was unsure about the assessment, and the DON confirmed the dialysis-related orders were not re-entered after hospitalization.
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.
Incomplete MAR/TAR Documentation: A resident’s clinical record showed active orders for Trazodone, TED stockings, Miconazole powder, and Biofreeze gel, but the May MAR/TAR lacked documentation that the medication and treatments were administered on multiple occasions. The record review and findings were confirmed with the DON.
Incomplete and inaccurate charting was found for three residents. A resident had Flonase documented as given even though it was not available, an LPN signed for a dose she did not administer, another resident’s TAR showed held Dexcom and insulin treatments without the required nurse notes, and a resident with a right AKA had inconsistent wound documentation with repeated notes that the wound was not evaluated, no clear record of wound progression, and no documentation showing when or how dehiscence occurred.
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.
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