Incomplete documentation of a resident skin tear and incident. A resident with cancer, depressive disorder, and chronic respiratory failure sustained a left arm skin tear during a transfer when the arm contacted a grab bar. The RN/UM said she initiated the wound order but did not document the incident or complete an incident report, and the DON was not aware of the event. Record review showed wound and treatment orders, but the EMR did not clearly document the occurrence as required by facility policy.
Incomplete and inaccurate documentation of resident treatments and assessments: A resident with contractures had palm protectors and PROM ordered, but observations showed the devices were not in place and the TAR/CNA records did not consistently show completion or resident tolerance. Another resident with hemiplegia had a right hand T-bar orthosis ordered, yet observations found the splint absent and the TAR/CNA documentation was incomplete. A third resident reported a hot beverage spill to the groin and legs, but skin assessments were not current and no recent assessments were available in the record.
Incomplete and inaccurate resident medical records were identified for three residents. One resident’s chart lacked PASARR documentation despite psychiatric diagnoses and moderate cognitive impairment, another resident’s MAR showed Trulicity as given even though the LPN said it was not administered because it was out of stock, and a third resident’s dialysis communication forms were missing from the record, with many forms found outside the chart by the DON.
A resident’s medical record was incomplete and inaccurate because the face sheet did not list diagnoses, yet a social service note documented depression and insomnia. Staff said diagnoses were being pulled from hospital records when face sheets were blank, but the SSD could only verify a history of insomnia and could not confirm depression. The Administrator and CCRN acknowledged delays in entering diagnoses and concern about incorrect diagnoses in the record.
Inaccurate documentation of resident treatments: an RN was observed spending much of her shift at the nurses station and on her personal cellphone while charting treatments as completed that had not been done. Two residents initially reported missed treatments, and further review identified five additional residents whose ordered wound and skin treatments were also not completed despite being documented in the EMR as done. The DON confirmed the inaccurate charting and that the facility expects real-time, accurate documentation.
Incomplete and inaccurate documentation was found for three residents. One resident with osteomyelitis, a stage IV sacral wound, and a wound vac had multiple blank TAR entries for wound care, PICC dressing changes, and weights, with staff giving conflicting statements about wound vac documentation. Another resident with bilateral AKA, MS, and a stage II pressure injury had missing TAR documentation for weights, wound care, and suprapubic cath care. A third resident had a PRN acetaminophen dose given for pain, but the MAR was blank for the medication, pain level, administering nurse, time, and effectiveness.
Failure to document VS during acute changes in condition for two residents. One resident with hypertensive heart disease became lethargic, minimally responsive, and unable to take AM meds, but the RN did not record VS unless abnormal and the last full VS entry was several days earlier. Another resident with severe dementia and PNA had tachypnea, wheezing, diaphoresis, and low SpO2, yet the record showed gaps of about 24 hours or more without progress notes or VS while on antibiotics.
Incomplete guardianship documentation was found for a resident with a history of Alzheimer’s disease, dementia with behaviors, anxiety, personality disorders, and a prior stroke. The resident’s expired Letters of Guardianship were not present in the EMR, and the record did not show any documentation that the court had been contacted for current papers or a court date. The SSR stated the documents had been sent for filing, were lost, and had not been scanned into the resident’s record.
A resident with chronic respiratory failure and ventilator dependence was transferred to the hospital for abnormal pulse oximetry, but the EMR did not include an assessment or other documentation showing a change of condition that justified the transfer. The record showed oxygen saturation readings above the ordered threshold and no nursing assessment on the date of transfer, while the transfer form and progress note listed only abnormal pulse oximetry as the reason.
A facility failed to keep complete and accurate MAR/TAR documentation for multiple residents, with missing entries for meds, wound care, catheter care, blood glucose checks, vital signs, skin checks, and other ordered monitoring. One resident with Parkinson’s disease, another cognitively intact resident who reported inconsistent meds and treatments, and several residents with wounds, diabetes, or a Foley catheter all had blank or incomplete records for ordered care, and the DON acknowledged prior citation for the same issue.
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