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.
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.
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 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.
A resident admitted with a Foley catheter had an incomplete and inaccurate admission H&P. The MD started the H&P before seeing the resident and later completed it without documenting the Foley, urinary incontinence/retention, or related urinary diagnoses, even though the hospital discharge summary and physician orders reflected urinary issues and catheter use.
Incomplete immunization documentation was found for four residents whose COVID-19 vaccine records were either missing or not fully completed. One resident’s refusal form lacked the resident’s name, date, and signature, another resident’s declination had no date or indication of who declined it, and two residents had no completed COVID-19 consent form or documented vaccine status in the chart. Staff stated the vaccine status was kept on the IP’s personal tracker instead of in the residents’ medical records.
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