Incomplete and inaccurate documentation was found for two residents. One resident with dementia and an elopement risk was observed outside near the driveway after a leave of absence, but the event, the guardian notification, and related details were not documented in the chart. Another resident with Huntington's disease and full code status had late and incorrect documentation of vital signs and CPR events during a terminal episode, and the record did not note that ventilations were not provided during CPR.
Incomplete documentation of a resident-to-resident altercation was found for two residents with behavioral and psychiatric diagnoses. Records for both residents lacked any progress note about the incident, and an LPN’s risk assessment was incomplete and did not include the alleged event. Staff interviews confirmed the altercation should have been documented and reported, and one resident later stated the other resident punched her in the face.
Failure to document a change in condition: A resident with COPD, DM, PVD, and vascular dementia returned with a wound vac for a chronic leg ulcer, and staff later found fly maggots in the wound dressing. The DON, ADON, and LPN confirmed the finding and that documentation of the wound change and resident/family notification was not entered in the medical record, despite facility policy requiring changes in condition to be recorded.
Incomplete documentation of resident burn incidents. A resident with DM II, COPD, emphysema, and chronic respiratory failure was burned while smoking with oxygen on, but nursing progress notes did not document two burn events. The resident stated he forgot to remove his oxygen before smoking and had been using zinc oxide cream on his nose from a prior burn. The MD note reflected a skin burn, while the RDCS, ADON, and MD reported they were unaware of the incidents and the chart lacked documentation.
A resident with diabetes, renal failure on dialysis, multiple amputations, and surgical wounds had repeated inaccurate charting of ordered wound care and wound assessments. Staff documented treatments and assessments as completed on the TAR even though the DON and ADON verified the right-hand dressing had not been changed since the prior shift and the left upper extremity wound had not been assessed. The resident reported the wound care was often not done, and a skin evaluation was also found inaccurate because it recorded measurements while the dressing was still in place.
Inaccurate post-fall documentation was found for a resident with dementia, impaired cognition, and fall risk. After the resident fell and was sent to the hospital with a skin tear, sutures, and rib fractures, the chart showed neuro checks as completed while she was actually at the hospital. The RCD verified the record was inaccurate because the resident was not present for those assessments.
Incomplete MAR Documentation for Refused Medications: A resident with multiple chronic conditions, including CKD, DM2 with neuropathy, functional quadriplegia, and chronic respiratory failure, had blank MAR entries for scheduled Morphine, Lorazepam, and Ativan doses. The RDCS verified the meds were not signed off as refused, despite facility policy requiring staff to initial and circle the MAR entry when a med is refused.
Incomplete and inaccurate resident record documentation: Multiple resident charts lacked complete documentation of transfers, outcomes after ER/hospital send-outs, and medication/treatment administration. One resident’s TPN was charted as “see progress notes” without the RN who started it signing off, several residents’ records did not show what happened after transfer, and one ventilator-dependent resident’s code event was documented with incorrect times and notification details. The DON confirmed the charting errors and missing documentation.
Incomplete and inaccurate medical records were found for three residents. One resident’s fall from a wheelchair was confirmed by the DON and family representative but was not documented in the chart, another resident’s PEG tube bolus feeding orders were not clearly reflected on the MAR to show whether the feeding was given or held based on meal intake, and a third resident’s wound was inconsistently documented as both Stage II and Stage III in the skin records, despite wound care notes and the care plan identifying it as Stage III.
Accurate medical records were not maintained for a resident with CHF, HTN, and generalized weakness. The chart included inconsistent MDS, therapy, and care plan information about mobility and transfer status, including a mechanical lift intervention that did not match therapy orders at the time and was not updated when orders changed. A nursing note also documented a shower, new left arm pain, and treatment orders while the resident was actually in the hospital.
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