The facility failed to ensure complete and accurate clinical records for two residents who required extensive staff assistance with ADLs, including personal hygiene and toileting. Despite documented needs such as a left femur fracture with Alzheimer’s disease and paraplegia with staff dependence for care, the NA Point of Care records for a specific day shift contained no entries showing that ADL assistance was provided. A complainant alleged inadequate staffing and lack of assistance for one resident during that shift, and the ADNS acknowledged that NAs did not document the care provided as required by professional documentation standards.
A resident with type 2 DM, who was cognitively intact, reported not receiving a scheduled Mounjaro injection even though an LPN documented the dose as given on the MAR. Pharmacy delivery records and the narcotic count book showed that all Mounjaro pens remained in the refrigerator and on the count for several days, contradicting the MAR entry. An RN supervisor and another staff member verified that the narcotic count and physical inventory had not changed, and the ADON later found that the count did not decrease until days after the documented administration. The LPN admitted entering the narcotic record late, despite facility policy requiring immediate documentation, and leadership could not substantiate that the recorded administration actually occurred.
Two residents had incomplete medical records related to outpatient specialist visits. One resident with heart failure and a recent fall had a general surgery follow-up that was canceled and rescheduled, but the COC was missing and later appointments were not documented as completed; the scheduler was unaware of the follow-up visits and transport was not arranged. Another resident with a failed hip arthroplasty returned from an ortho visit with instructions for dental clearance, bone health evaluation, bone density testing, and cardiac clearance, but the COC was not in the chart and the instructions were not shown as reviewed or implemented. The DON/DNS could not produce the missing records and cited delayed scanning.
Inaccurate Documentation of 24-Hour Fluid Intake: A resident with ESRD and dependence on renal dialysis was on a 1500 mL daily fluid restriction, and a physician ordered staff to total the 24-hour fluid intake on 3rd shift. Review of the MAR showed the resident's daily fluid intake was not accurately totaled for 24 of 24 opportunities until the issue was identified by the surveyor. An LPN and the DON acknowledged the inaccurate documentation.
Incomplete medication and wound treatment documentation affected two residents. One resident with infected heel wounds had metronidazole transcribed incorrectly from TID to BID, resulting in fewer doses than ordered, and another resident with a right-hand skin tear had a wound treatment documented as completed even though the dressing remained dated and appeared soiled when observed. The DON and unit manager acknowledged the documentation issues.
A resident with a skin tear and a history of stroke had a wound care order for daily cleansing and dressing changes, but surveyors observed the dressing was still dated from several days earlier. The TAR showed the treatment as completed on two days when the RN acknowledged it had not been changed, and the DON could not provide evidence that the medical record was accurately maintained.
A resident with a complicated UTI had an order for Meropenem 1 gm IV three times daily in normal saline. Although Meropenem and normal saline were listed as available in the IV E-kit, review of the E-kit utilization form showed they were not removed for use, and pharmacy records indicated the medication was not delivered until the following evening. The resident missed three ordered doses, yet the February MAR showed Meropenem as signed out and documented as administered for two of those times when it had not been given. The DON confirmed the medication was not administered until after pharmacy delivery and could not show that the MAR accurately reflected the missed doses.
A resident with a history of food in the respiratory tract and an MDS indicating a need for partial/moderate assistance with eating had a physician’s order for staff to assist with meals at all times on day and evening shifts. Surveyors observed the resident eating independently in a common area without staff assistance during midday meals, while the Treatment Administration Record showed the ordered meal assistance as completed for those shifts. An RN acknowledged documenting the order as completed even though he did not assist the resident, had delegated the task to NAs, and did not know whether any NA had actually provided meal assistance. The DON stated she expected staff to follow physician orders and document accurately.
A resident with dementia and neuromuscular dysfunction experienced a witnessed fall from bed while one staff member was assisting with turning. Record review showed the resident was dependent for rolling in bed, and the ADL care plan for impaired mobility contained conflicting bed mobility interventions: one entry required two staff and a sheet for turning and repositioning, while a later entry required only one staff and a sheet. The earlier intervention was not removed, leaving the care plan incomplete and unclear about the resident’s actual assistance needs. During interview, the Regional Clinical Director and DON acknowledged the discrepancy and were unable to show that the care plan accurately reflected the resident’s needs.
Incomplete MAR and skin documentation were identified for two residents. One resident with hypotension had Midodrine documented as given despite BP readings above the hold parameter, and the MAR was later altered after staff said the doses were not actually administered. Another resident with a left heel blister/callous had treatment orders in place, but weekly skin checks did not consistently document the heel impairment, even though surveyors observed a hardened non-blanchable area and the ADNS acknowledged the omission.
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