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 intact cognition and cardiac and pulmonary comorbidities, who had documented DNR/DNI status, experienced a change in condition characterized by respiratory distress and chest discomfort. Staff, including an LPN, RN supervisor, and DON, assessed the resident, applied oxygen, attempted IV access, confirmed DNR status, and were present when the resident expired, after which the DON pronounced death and notified the family and funeral home. Despite facility policy requiring detailed documentation of changes in condition, assessments, pronouncement details, notifications, and post-mortem care, no nursing progress note was entered in the medical record describing the resident’s decline, death event, or related notifications, resulting in an incomplete clinical record.
Incomplete documentation of PRN oxygen administration. A resident with COPD, CVA, seizure disorder, and severe cognitive impairment had an order for oxygen at 2 L/min via NC as needed to keep O2 saturation above 90%. Surveyors observed the resident receiving oxygen on multiple occasions, but the MAR/TAR had no nursing signatures showing the PRN oxygen was administered. Staff stated the oxygen was applied when the resident became short of breath and desaturated, but it was not documented as required.
Three residents with cognitive and chronic medical conditions received influenza and/or COVID-19 vaccines from an outside pharmacist during a vaccine clinic, but the facility’s MAR and immunization records inaccurately documented that facility nurses administered these vaccines or left the administrator information incomplete. Facility policy required that immunizations be documented by the nurse who administered them and that vaccines given by non-facility staff be entered as outside-agency or historical immunizations in the EMR, rather than as standard MAR entries. An LPN reported signing the MAR for vaccines they did not administer, based on verification forms and resident reports, while another LPN stated they only entered orders and did not give any vaccines, despite being listed as the administering nurse. Leadership and nursing staff acknowledged that nurses should not document medications they did not administer or witness, yet the records continued to reflect inaccurate or incomplete documentation of who actually gave the vaccines.
A resident with chronic pain, a history of falls, and moderately impaired cognition slid from a wheelchair to the floor, as documented by an OTA. Despite facility policy requiring documentation of all incidents, accidents, and changes in condition, there was no nursing or MD documentation of any assessment following the event. An RN supervisor acknowledged being informed of the incident and not entering a progress note, and the DON confirmed that a nursing progress note should have been completed.
A resident with respiratory failure, OSA, and hypertension experienced an acute change in condition with labored respirations, decreased responsiveness, and very low O2 saturations. An LPN notified the RN supervisor, oxygen delivery was escalated from nasal cannula to mask and then to a non-rebreather, and EMS ultimately transported the now unresponsive resident to the hospital. Despite facility policies requiring RN assessment and detailed transfer documentation, there was no recorded RN assessment, no documented vital signs (HR, BP, RR, temp), and no documentation of the resident’s response to oxygen therapy, and the RN’s progress note entry remained blank, leaving the medical record incomplete and not in accordance with professional standards.
The facility did not consistently ensure that both incoming and outgoing nurses signed the controlled substance inventory sheets at each shift change, resulting in numerous missing signatures across multiple units. Despite clear policies requiring dual nurse verification and signatures for narcotic counts, staff interviews revealed that signatures were often omitted due to distractions, forgetfulness, or staff working double shifts. Supervisory staff confirmed that the records were incomplete and did not meet professional standards for accountability.
A resident with multiple chronic conditions had physician-ordered wound care for a right medial bunion, but the treatment administration record and nursing progress notes showed numerous dates where wound care was not documented as completed. Interviews with LPNs and facility leadership revealed uncertainty about whether the care was provided, and no documentation was found to explain the omissions, contrary to facility policy requiring complete and accurate medical records.
A resident with severe cognitive impairment and multiple medical conditions was documented as having received ADL care by a CNA who reported not providing or recording such care. Additionally, an LPN documented hourly rounding for the resident after the resident had expired and was removed from the facility. These actions resulted in inaccurate medical records, contrary to professional standards.
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