Inaccurate wound care documentation was identified for a resident with DM2, PVD, and osteomyelitis. The resident reported that a foot wound dressing ordered to be changed daily was often changed only every 2 days, while the wound NP documented multiple instances where the dressing had not been changed as ordered or the same dressing remained in place from the prior week. The MAR still showed wound care as completed daily during those periods, and Nursing Administration confirmed weekly rounds were the only audits done and that wound care supplies such as blue foam were sometimes hard for staff to locate.
A resident with prostate cancer and secondary bone cancer missed three doses of oral chemotherapy after the medication was inadvertently sent home with another resident at discharge. The DON and RN confirmed there was no progress note, medication error report, discharge inventory, or other medical record documentation showing the loss, the response, or the steps taken regarding the missing medication, despite the facility policy requiring such documentation.
A resident admitted with depression and visual hallucinations had expired conservatorship paperwork in the record, and the SW knew it was expired but did not follow up after an initial request for updated documents went unanswered. The care conference note did not document discussion of the conservatorship paperwork, and the facility’s records showed ongoing issues with updated guardianship paperwork and code status signatures.
The facility failed to maintain an accurate EMR for two residents. For one resident with cellulitis, sepsis, CKD, and adult failure to thrive, staff documented a decline in condition but did not record family notification or guardianship-related actions in the EMR. For another resident with TBI and bladder dysfunction, the care plan called for pain assessment and evaluation of morphine effectiveness, but the MAR and EMR lacked documentation of pain scores and response to medication.
Surveyors found that staff failed to maintain accurate and complete treatment documentation for multiple residents, including missing TAR entries for ordered compression stockings, skin care, wound care, and monitoring, inconsistent and unexplained use of an incentive spirometer order with no supporting progress notes, and conflicting records about nebulized Ipratropium-Albuterol treatments that residents and the NP reported were never given due to lack of equipment. Nurses sometimes charted treatments as completed or used the "07-Other/See Progress Notes" code without any corresponding notes, while leadership acknowledged there was no systematic oversight of treatment documentation, contrary to the facility’s own documentation policy requiring factual, complete, and non-false entries.
A resident with sepsis, UTI, cerebral infarction, and a positive COVID-19 test had multiple verbal orders for Paxlovid 300/100 mg BID entered and revised, with the MAR showing several doses marked as not given due to the drug being on order or unavailable, one dose lacking documentation, and two doses recorded as administered by an RN. Progress notes repeatedly stated the medication was not given because it was on order or unavailable, while pharmacy records confirmed Paxlovid was never delivered after the order was cancelled due to high cost, making the documented administrations inaccurate; the RN involved had a prior disciplinary action for falsely documenting medication administration.
The facility failed to maintain accurate MARs for two residents, leading to discrepancies between documented and actual medication administration. One resident with morbid obesity had an active order for weekly Wegovy injections, and the MAR showed a dose as given, but the pharmacist confirmed the drug was never supplied and the RN who charted it later stated it was likely a documentation error and did not recall administering the injection. Another resident with chronic pain had orders for scheduled and PRN Percocet; the MAR reflected five doses given on one day, while the controlled drug receipt and narcotic count supported only four tablets being dispensed. The LPN involved reported that the controlled drug record reflected what was actually administered and that the MAR entries were likely incorrect.
The facility failed to maintain a complete and accurate EMR for a resident involved in an altercation with another cognitively impaired resident. After staff heard a noise and found one resident on the floor with a bloody nose and another resident nearby with a balled fist, both making threatening statements, an incident form documented that the injured resident reported being struck. However, the alleged aggressor’s EMR contained no progress notes or entries about his involvement in the incident, despite staff interviews indicating that such events should be documented, including assessments, vitals, and communication with the NHA and physician.
Incomplete Hospice Documentation in Resident Record: A resident with cirrhosis, kidney failure, HF, DM, anxiety, and depression had an EMR that lacked Hospice visit notes for months, despite ongoing Hospice involvement and pain management concerns. The resident reported that Hospice and facility staff often disagreed about pain medication directions, while the CCC, Medical Records, and DON all verified that the most recent Hospice documents in the EMR and Hospice binder were outdated and that current Hospice recommendations for pain control could not be determined.
Incomplete Bowel and Bladder Documentation: The facility failed to maintain complete and accurate medical records for a resident with Alzheimer’s disease, depression, severe protein calorie malnutrition, and severe cognitive impairment. The care plan called for toileting assistance with a 2-person sit-to-stand mechanical lift, but bowel and bladder documentation was incomplete across multiple months, and the DON acknowledged the gaps in documentation.
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