Incomplete CNA Documentation of Resident Care: CNA charting for multiple residents was missing for numerous shifts, despite care plans requiring documentation of ADLs, transfers, toileting, eating, skin checks, and other care. Residents with dementia, fractures, COPD, CHF, diabetes, and significant assistance needs had gaps in EMR entries, and staff reported that documentation was often delayed or not completed because of workload, staffing shortages, and competing responsibilities. RNs and the DON stated the charting was not consistently up to date and that staff had to rely on what was documented.
An LPN inaccurately documented medication administration, vital signs, and resident monitoring for a severely cognitively impaired resident with dementia, bipolar disorder, CHF, and elopement risk. The LPN later stated they did not perform the required rounds, did not enter the resident’s room, and did not actually give the medications, despite signing the MAR and treatment record as if they had. Video surveillance showed the resident leaving through an alarmed exit shortly after midnight, while the resident was not identified as missing until hours later.
A resident with a MOLST and physician orders for DNR/DNI was found unresponsive, but the RN supervisor and LPN could not locate the code status in the EMR or find the MOLST at the nurses’ station. Because the DNR order had been de-activated after a hospital stay and not re-entered, staff treated the resident as full code, activated Code Stat, and CPR and intubation were performed until the resident was pronounced deceased.
Incomplete Documentation of Discontinued Contact Precautions: A resident with an indwelling catheter, neurogenic bladder, diabetes, and hemiplegia had contact isolation precautions documented in the care plan and physician orders for VRE, Klebsiella, and Pseudomonas. Staff stated the precautions were verbally discontinued when IV antibiotics were stopped, but the EMR was not updated for several days, no nursing progress note was written, and contact isolation signage was not posted outside the room during observations while EBP signage remained in place.
A resident’s chart contained repeated inaccurate NP documentation stating the resident had multiple pressure areas, despite later review and staff statements that the resident had no open wounds. The resident had significant neurologic and mobility-related diagnoses, and the facility’s records were not documented objectively and accurately as required.
Incomplete documentation of physician notification and missed IV antibiotic therapy: A resident with UTI, COPD, and DM had an order for IV ceftriaxone, but the peripheral IV was dislodged and the resident refused reinsertion and treatment. Nursing notes showed the refusals and missed doses, yet the record did not document physician notification or the MD's assessment and communication about the change in treatment.
Missing documentation in resident records and narcotic counts: one resident’s pain med order was changed without a signed verbal order in the chart and without MAR documentation showing the scheduled doses were administered, another resident had missing CNA care entries for multiple shifts, and an LPN signed the narcotic shift count in advance instead of at the actual shift change.
Surveyors identified multiple failures in documentation and protection of resident information, including incomplete narcotic count records on several units where nurses either omitted required shift-change signatures or signed off in advance of the end of their shifts, sometimes only signing when prompted. A resident with anxiety disorder, macular degeneration, and asthma had nebulizer tubing changes documented on the treatment administration record that did not match the date on the tubing observed at bedside, indicating inaccurate treatment documentation. Additionally, two medication cart laptops were found open, logged in under nursing staff accounts, and left unattended with resident-identifiable information visible, while nursing staff were away from the carts.
A resident with multiple chronic conditions and numerous scheduled medications had repeated discrepancies between scheduled morning medication times and documented administration times. On multiple days, all medications ordered for a 9:00 a.m. pass were documented as given around midday by an RN, contrary to policy requiring timely administration and immediate electronic documentation. The RN cited computer timeouts, possible late documentation, and workload pressures, while leadership acknowledged that a single nurse was responsible for passing medications to roughly 40 residents within a limited time window and that MAR review was primarily done by the passing nurse and through monthly reports, with no routine MAR review by the pharmacy consultant.
A resident with dementia, depression, HF, and DM was transferred to the hospital after worsening SOB and never returned, yet BH notes later appeared in the facility record documenting in-person encounters, alert orientation, stable mood, and ongoing psych services. Interviews with the LMHC, BH regional manager, and DON confirmed the resident was not back at the facility and they could not explain why documentation from another facility was reflected in the resident’s chart.
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