A resident with dementia, anxiety, delirium, disorientation, and agitation had incomplete records for behavioral symptoms and anti-anxiety medication effects. Staff noted follow-up for behaviors and an order for Haldol due to increased behaviors, but did not document what the behaviors were or why lorazepam was discontinued. The MAR also did not show any behaviors or side effects, even though leadership stated lorazepam was making the resident drowsy and staff were expected to document behaviors, interventions, and medication side effects.
A resident admitted with acute pyelonephritis, hypothyroidism, and type 2 DM had a small open shearing area on the coccyx documented on admission, but no MD order or treatment record was obtained for the wound. The WCN stated the resident only received barrier cream that was not ordered, and the DON confirmed the admission nurse failed to obtain orders for the coccyx shear.
Incomplete Documentation of Resident Change in Condition: A resident with pneumonitis, COPD, and chronic respiratory failure developed a new cough that led an LPN to notify the MD and obtain a verbal order for azithromycin for a lung infection. However, neither the resident’s change in condition nor the provider communication and assessment were documented in the medical record, and the DON confirmed these events were expected to be recorded.
Medical records were incomplete for two residents with PEG tubes when staff failed to document PEG flushes. One resident had PEG medication orders that were later discontinued, and the RN said she flushed the tube twice daily but did not chart it. The other resident had PEG hydration and medication flush orders that were later changed to PO, and the RN said she flushed the tube daily but also failed to document it. The DON and NP confirmed staff were expected to flush PEG tubes at least daily when not in use and to document the flushes.
Incomplete and inaccurate resident records were found when PASRRs omitted documented mental health diagnoses, a wound-related diagnosis was not updated after a provider note identified a chronic stage 4 pressure injury, staff did not document repeated attempts or refusals when offering lotion for very dry feet, and the chart lacked documentation of provider communication about changing levofloxacin from IV to PO.
Incomplete documentation affected a resident with a PEG tube, another resident transferred for chest pain, and a third resident discharged from the facility. Staff did not record PEG placement departure/return details, feeding administration, residuals, or time off the pump; they also failed to document the circumstances of a hospital transfer and key discharge details such as status, who the resident left with, education, and any meds or equipment sent.
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.
Incomplete and inaccurate resident records were found for two residents. One resident’s hospice orders and physician orders did not match for the medication dose, duration, and diagnosis, and the chart also failed to clearly document the respiratory illness being treated even though the family reported pneumonia and a hospice note described antibiotics, cough, and crackles. Another resident’s care plan listed bladder incontinence related to neurogenic disorder, but the medical record did not support that diagnosis, and the MDSC confirmed it was entered by mistake.
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.
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