A resident with polyneuropathy and left knee pain had a PRN order for oxycodone-acetaminophen for moderate to severe pain. Review of the controlled drug record showed that staff signed out one tablet of the narcotic at a specific time, but the corresponding dose was not documented on the MAR. The DON confirmed that facility practice requires all narcotic administrations to be recorded on both the controlled drug record and the MAR, and that this did not occur.
Surveyors found that a document containing multiple residents’ PHI, including full names, room numbers, and code status, was left unattended and visible on a south nurse’s station counter. An RN confirmed the document was a resident list with PHI and acknowledged it had been left exposed and that such information should not be left unattended.
Staff failed to protect residents' PHI by leaving multiple types of documents containing identifiable information, including CNA shower lists, face sheets, and vital sign lists, unattended and exposed on treatment/medication carts in hallways. These documents were observed on several occasions on different units, visible to anyone passing by. An LPN, an RN, and a CMA each confirmed that the documents were left exposed and acknowledged that resident-identifiable information and PHI should not be left unattended.
Surveyors found that the facility failed to maintain complete and accurate medical records for two residents. For one resident with an abdominal surgical wound, the TAR showed wound care as completed each shift, but progress notes and a communication form later revealed the dressing had not been changed for several days, with increased drainage, redness, purulent discharge, and a culture positive for gram negative and gram positive bacteria. For another resident who experienced a CIC, vital signs taken afterward were not documented in the EHR. The DON confirmed that wound care documentation on the TAR was inaccurate and that the vital signs following the CIC were not entered as required.
A resident with a gastrostomy tube and orders for Jevity feedings, water flushes, residual checks, and PEG-tube medications had multiple instances where bolus and continuous enteral feedings, water flushes, and residual volume checks were not documented on the MAR, even though PEG-tube medications were recorded as given. LPNs reported that they followed all enteral feeding and residual check orders, but these actions were not reflected in the medical record, and the DON confirmed that numerous feedings, flushes, and residual checks lacked documentation, resulting in incomplete and inaccurate medical records.
Incomplete wound care and medication documentation: Staff failed to document wound care for one resident with a coccyx pressure ulcer and wound vac, failed to document zinc barrier cream administration for another resident, and failed to document wound care and repositioning for a third resident. The ADON and DON confirmed the missing MAR/TAR entries, and staff stated documentation should be completed when care is provided.
Two residents with indwelling Foley catheters had care plans indicating catheter use, but no corresponding physician orders were documented in their medical records. Review of the charts showed that, despite the presence of Foley catheters noted in the care plans, the physician order sections contained no entries authorizing or detailing the catheters. In an interview, the UM confirmed that staff had not entered the Foley catheter orders into the records and acknowledged that these orders should have been documented.
Surveyors found that wound care orders for two residents’ buttock wounds were not accurately documented on the Treatment Administration Record (TAR). One resident’s ordered daily wound care was missing documentation on multiple specific days, and another resident’s ordered wound care lacked documentation over an extended period. The Wound Care Nurse reported that she completed the ordered treatments on numerous dates but did not record them on the TAR, sometimes relying on the unit nurse to document instead. This resulted in incomplete and inaccurate medical records related to wound care.
A resident with DM2, depression, anxiety, and dementia was receiving Risperidone, but the consent form on file listed schizophrenia as the indication while the current MD order listed dementia without behavioral disturbance. A pharmacist’s review noted that consent for Risperidone related to dementia with behavior disturbance could not be found and requested an update to the record. The MDS regional coordinator later confirmed that the consent did not match the current physician order, demonstrating the facility’s failure to maintain an accurate and updated medical record for this medication.
A resident with HTN and cardiac conditions had a physician order for carvedilol to be held only if SBP was below a specified threshold or HR was under 60 bpm. On two occasions, the MAR showed carvedilol doses as not administered with instructions to see a nurse or progress note, even though the recorded vital signs were within ordered parameters for administration. No corresponding nursing or progress notes were found to explain why the doses were held, while other doses with similar vital signs were documented as given. The DON confirmed that when a medication is marked as held with a direction to see a note, a note explaining the reason is expected, and acknowledged the medical record was not accurate.
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