Two residents had inaccurate medical record documentation. One resident with diabetes had insulin and blood sugar checks documented as on time even though the LPN later admitted the lunch check and Humalog were several hours late and the MAR was charted inaccurately. A former resident’s chart also contained inconsistent wound documentation and progress notes listing wounds and medications that were not supported by the skin checks, physician orders, MAR, or hospital discharge information.
Failure to document a wandering and disrobing incident involving two residents. One resident with schizoaffective disorder, bipolar disorder, CHF, hepatitis C, diabetes, severe cognitive impairment, and wandering behaviors, and another resident with dementia, psychosis, COPD, diabetes, severe cognitive impairment, and verbal behaviors were involved in an event where one resident entered the other's room and both were found partially disrobed. CNA witness statements described the incident, but the DON verified there was no corresponding documentation in either resident's medical record.
Missing Documentation for Incontinence Care: Three residents with significant toileting needs and bowel/bladder incontinence had multiple gaps in incontinence care documentation across several months. One resident was cognitively intact, one had moderate cognitive impairment, and one had severe cognitive impairment; all required staff assistance with toileting, and the Administrator confirmed the care tasks could not be verified because they were not documented.
Incomplete and inaccurate documentation was found for two residents. One resident had ordered weekly weights and BID blood glucose checks, but refusals, reattempts, and multiple glucose results were not entered into the EMR even though some information appeared on handwritten sheets and dietitian reports. Another resident’s MAR did not reflect multiple documented administrations of PRN hydromorphone shown on narcotic count sheets, and the DON confirmed medication administration was not being accurately documented on the MAR.
A facility failed to keep resident records accurate and complete. Documentation was missing for hospice services, skin bruising and an incident-related injury, wound care that was charted as done but was not completed as ordered, a resident behavior involving stool ingestion and a related change in condition, leg treatment when supplies were unavailable, and Foley catheter care that was charted as completed despite staff stating it was not provided. Staff interviews and record review confirmed the documentation gaps and inaccuracies.
Medical record documentation was incomplete for a resident with schizophrenia, DM2, and depression who had moderately impaired cognition and was independently mobile. The chart lacked progress notes showing the resident left the facility without staff knowledge and that his whereabouts were unknown, even though the facility investigation and SRI documented that staff searched for the resident, activated the missing resident protocol, and contacted police. Staff confirmed the incident was not documented in the medical record.
Incomplete records, missing anticoagulation monitoring, and inaccurate documentation were identified for several residents. An LPN and RN confirmed PT/INR orders were not entered into the EMR for residents on warfarin, and there was no documented follow-up for lab results or physician notification. Staff also described an instance where a dressing was dated after the fact, and interviews confirmed inaccurate admission weights and a missed weekly weight for a resident with a tube feed and severe cognitive impairment.
Incomplete and inaccurate charting affected three residents. One resident had conflicting diabetes diagnoses across admission paperwork and provider notes, and the DON could not verify the correct diagnosis. Another resident had weekly skin checks marked complete on the TAR, but no nursing notes documented the findings. A third resident’s readmission skin assessment did not match nursing progress notes and hospital documentation showing a stage 3 heel pressure ulcer, sacral redness, and lower-leg wounds.
Inaccurate neurological assessment documentation followed unwitnessed falls for two residents. One resident with severe cognitive impairment had neuro checks charted after hospital transfer, including a documented 11:00 A.M. assessment even though hospital records showed the resident was already at the hospital. Another resident with multiple chronic conditions had neuro checks charted during a hospital stay, and staff confirmed the entries did not match the resident’s actual location or the care provided. Facility policy required accurate dating and timing of neuro assessments and proper correction of charting errors.
Accurate medical records were not maintained for two residents. One resident’s weekly skin checks noted skin areas, but no corresponding assessments were found, despite documentation suggesting the entries related to treatment of abdominal/breast folds and bilateral buttocks. Another resident with dementia and hearing impairment had inconsistent documentation of family notification for changes in condition and orders, including a STAT KUB for GI symptoms and a telehealth visit for increased confusion with new orders; the DON confirmed the missing documentation.
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