Incomplete hospice and PASARR documentation in a resident record. A resident with depression and schizoaffective disorder had hospice status changes and discharge information that were not reflected in the EHR, including missing physician orders and nursing notes that continued to show hospice after discharge. The record also lacked the completed Level II PASARR evaluation after a Level I screen triggered it.
Incomplete Hospice and dialysis records, along with an PHI privacy breach, were identified for multiple residents. A resident receiving Hospice had no current Hospice plan of care or visit documentation in the EHR or unit binder, and a resident with ESRD and cognitive impairment had missing dialysis communication, pre/post treatment records, and vital signs. In a separate event, a nurse went to another resident’s home to retrieve medication, which was acknowledged as a violation of that resident’s PHI.
A resident’s POLST was mistakenly sent home with another resident’s discharge paperwork when both residents were discharged. The LPN/Resident Care Manager and RN/DON stated the facility routinely placed the original POLST in discharge paperwork, and staff acknowledged that sending one resident’s POLST with another resident’s documents was improper and a HIPAA violation. The issue was identified as a repeat citation.
Inaccurate Meal Intake Documentation: A resident with DM, dysphagia, and protein-calorie malnutrition was observed eating less than 25% of a meal, but the POC documented 76-100% intake. The CNA said the resident usually ate only 25-50% of meals and that intake was sometimes documented based on what a coworker reported. The LPN/RCM and DON stated meal intake should be documented accurately.
Inaccurate documentation for a resident’s albuterol inhaler SMP was found when the MAR showed the inhaler ordered TID at 8:00 AM, 2:00 PM, and 9:00 PM, but the TAR was charted as if the SMP occurred every 4 hours. An RN, RCM, and DON all stated the SMP order should have matched the inhaler schedule, and the DON also noted the TAR incorrectly marked the resident as hospitalized when the resident was not in the hospital.
Resident records were not kept accurate, complete, or readily accessible. One resident’s guardianship letters had expired and staff did not know they needed updating, another resident on hospice lacked a current hospice certification and had missing hospice visit notes, and a third resident’s chart contained conflicting discharge paperwork showing both a hospital transfer and discharge to an AFH.
Two residents had their meal intake inaccurately and prematurely documented by CNAs, including one case where a resident who ate only a few bites was recorded as having consumed more than half of the meal, and another where a resident still actively eating more than half of their tray was documented as having eaten only 25–50% while the meal was ongoing. A family collateral contact also reported that recorded intake did not match what they observed during meals, and the DON confirmed that staff are expected to document accurate intake only after meals are completed.
The facility failed to accurately document two significant resident incidents in the medical record. In one case, a resident was struck in the head by another resident in the dining room, but no progress note entry was made for the resident who was hit. In another case, a cognitively intact resident choked during lunch, became unresponsive, and staff performed the Heimlich maneuver, initiated CPR, called 911, and the resident was transported to the hospital; however, the progress note omitted documentation of provider notification and the subsequent emergency interventions and transfer. These omissions did not meet accepted professional standards for medical record documentation.
Incomplete and inaccurate charting was identified for two residents. One resident with hereditary spastic paraplegia and bladder dysfunction had a care plan that did not specify the catheter type or catheter-specific care instructions, and the MAR/TAR showed multiple missing entries for catheter output. Another resident with DM2, a bladder infection, and HF had missing MAR/TAR documentation for medicated vaginal cream, drain output, and ear drops. An LPN/Resident Care Manager stated charting was expected to be completed by nursing staff and CNAs, with missing documentation reviewed daily, though agency staff were harder to hold accountable.
Inconsistent code status documentation was found for a resident reviewed for advance directives. The POLST and EHR listed Attempt Resuscitation/CPR, while the care plan and PT note listed DNAR. Staff confirmed the records did not match and stated code status should be consistent across the POLST, EHR, care plan, and therapy notes.
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