Inaccurate medication transcription led to two residents not receiving ordered therapy as documented in the MAR. One resident with ESBL UTI received Ertapenem at 1 g IV daily instead of 500 mg IV daily, and another resident with HF and CKD missed multiple Bumetanide doses after the order was entered with the wrong start date. The RN and DON/DNS acknowledged the transcription errors.
A resident’s closed record was missing a discharge summary. The resident had been admitted with AFib and DM and was later found deceased in the room and pronounced dead. The SW, Medical Records staff, and the Administrator were unable to provide evidence that the discharge summary had been completed.
Incomplete Transfer Documentation: A resident with muscle weakness and gait impairment had transfer orders and care plan interventions that required a stand aid with 1 staff assist, while a room white board and PT staff identified the resident’s transfer status as stand pivot with 1 staff assist. The DON acknowledged the order and care plan were not updated when the resident’s transfer status changed.
Inaccurate Ventilator Documentation: A resident with Duchenne muscular dystrophy, chronic respiratory failure, and ventilator dependence had records that did not match actual NIV use. The chart showed the nighttime LTV was discontinued and VOCSN was started, but the TAR continued to document the LTV with ordered settings on multiple later dates. The PA said staff should document accurately, and the DON could not provide evidence that the medical record was accurate.
A resident with ESRD and dialysis dependence had an order to monitor a right chest wall permacath each shift, but the record showed the permacath had been removed while the MARs continued to be signed off as if the order was still active. The DON confirmed the device had been removed and stated staff should not sign off on an order that was no longer accurate.
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.
Incomplete observation, splint, and G-tube documentation was found for three residents. A resident on 15-minute checks after an altercation had multiple gaps in the observation record, an LPN signed off that another resident’s hand splints were completed even though the splints were not on the resident and were found in a drawer, and a resident with a G-tube had inconsistent flush documentation on the MAR/TAR despite a physician order for 30 mL before and after each feeding.
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.
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