A resident with cerebral infarction, COPD, DM, muscle weakness, and a fall history had an inaccurate progress note after a fall involving a rollator walker; staff observed the resident seated on the walker when the front wheels caught in a gap in concrete, but the chart described the resident as walking and being lowered to the floor. The facility also failed to document another resident’s medical decision-making capacity on admission, despite H&P and psych records referencing deferral to psych and later documentation showing the resident lacked capacity.
Inaccurate PICC line dressing documentation: A resident with a PICC in the right upper arm had the dressing and Stat-lock documented as changed in the MAR before the task was actually completed. RN 2 confirmed the dressing and Stat-lock were last changed a week earlier, and the DON verified the record did not match the actual care provided. RN 1 stated she documented the task as completed but forgot to update the record accordingly.
Inaccurate fall history documentation was found for a resident with dementia, a history of falls, and a left wrist fracture. The chart showed a fall and a fall risk assessment indicating multiple recent falls, but a later fall risk evaluation incorrectly stated there were no falls in the past 3 months despite another documented fall. The DON verified the documentation was not accurate and stated the facility’s falls and charting policies were not followed.
Incomplete documentation of individualized activity visits and resident response: A resident with autistic disorder, HTN, and lymphocytic leukemia had a care plan and activity note reflecting preferred room visits twice weekly, but the activity record only showed three room visits and did not identify the specific activities provided or the resident’s participation and response. The resident reported the visits were not consistent and that he felt deprived of social interaction, while the AD and DON stated the activity staff did not document each room visit in the medical record as required.
Incomplete documentation of meal assistance and intake. A resident with stroke-related right-sided weakness and dysphagia was totally dependent on one staff member for eating, but the chart had multiple missing entries for assistance with eating and amount eaten. CNA staff said they assisted the resident and documented intake electronically, while the DSD confirmed the ADL tasks were incomplete and the DON stated that anything not documented is not done.
Delayed and Inaccurate Documentation of Resident Behavior: An LVN documented a resident’s alleged aggressive behavior several days after the event rather than at or near the time it occurred. The resident had schizophrenia, anxiety, and epilepsy, and the record described intact cognition and the ability to understand and be understood. Video review did not support the documented aggression, and the ADM, LVN, and DON all acknowledged the note was not timely and that resident behaviors, incidents, assessments, and interventions were expected to be documented accurately in the chart.
Inaccurate Fall Risk documentation was found for two residents. One resident’s assessment was copied from an earlier form and did not reflect a recent fall, correct gait/balance findings, or the number of psychotropic, diuretic, antihypertensive, benzodiazepine, and narcotic medications being taken. The second resident’s assessments conflicted with each other and did not accurately show fall history, ambulation status, predisposing conditions, or the number of medications in the listed categories. Staff confirmed the forms contained incorrect documentation.
Incomplete Documentation of Turning and Repositioning: The facility failed to maintain complete and accurate records for two residents whose care plans required turning and repositioning every 2 hours. One resident had metabolic encephalopathy, acute kidney failure, dementia, and a coccyx pressure ulcer, while the other had Parkinson's disease, dementia, muscle weakness, and a history of pressure ulcers. For both residents, the TCADL and CNA charting did not show the required Q2 hour turning and repositioning, and staff interviews confirmed the missing documentation.
A resident’s IPE was left incomplete because the discharge receipt section was not signed or dated after the resident was transferred to the hospital and later did not return. The resident had COPD with acute exacerbation and HTN, was cognitively intact, and had items of value listed on the IPE, including a wallet, cell phone and charger, computer/laptop/e-reader, hearing aids, and eyeglasses. RN and DON interviews confirmed the family collected the belongings, but no one documented receipt on the form.
A resident’s EHR contained an Annual H&P that included H&P records belonging to five other residents. The MR/AD and DON confirmed the documents were uploaded into the wrong chart and should not have been there. The MR/AD stated documents were expected to be verified by name and DOB before upload, and both leaders stated the mix-up was a HIPAA violation and that records must be placed in the correct resident’s chart.
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