Two residents experienced deficiencies in clinical record documentation when multiple active physician orders for medications, treatments, monitoring, positioning, and meal-related care were not documented as completed on the MAR/TAR, and when a provider progress note contained outdated wound care and foley catheter information that did not match current orders. The DON confirmed that the records lacked evidence of completion for ordered interventions and that the provider note did not accurately reflect the resident’s current wound care regimen.
Incomplete neurological and wound documentation was found for two residents with unwitnessed falls and one resident with a right heel pressure injury. Neuro checks after falls were not fully documented at required intervals, and the wound record lacked staging, measurements, and description while the chart contained conflicting pressure injury stages from the RN, NP, and wound clinic records.
A resident with atrial fibrillation was receiving Eliquis (apixaban) twice daily as ordered, and the MAR showed doses were given as scheduled. Following two separate falls, staff completed SBAR Communication Forms and progress notes to notify the provider of the change in condition. However, on both occasions, the Background section under Medication Alerts on the SBAR forms did not indicate that the resident was on an anticoagulant, despite the form’s directive to complete relevant sections before contacting the MD/NP/PA. During interviews, facility leadership confirmed that the SBAR documentation for these falls failed to reflect the resident’s anticoagulant therapy, resulting in incomplete and inaccurate clinical records.
Incomplete MAR/TAR Documentation for Ordered Medications and Treatments: Multiple residents had missing MAR/TAR entries for ordered meds, treatments, assessments, and monitoring, including insulin and BG checks, wound and skin care, enteral feeding tasks, HOB elevation checks, psych med side-effect monitoring, and other ordered nursing interventions. The Market Clinical Advisor confirmed the missing documentation during interview.
The facility failed to keep provider orders current and organized by not discontinuing inactive or outdated orders for two residents. One resident was observed receiving O2 at 1.5 L/min via nasal cannula while the active orders still listed three separate O2 orders at 2 L/min, including PRN and continuous orders for SOB and to maintain O2 saturation at 90%. Another resident had been discharged from hospice and had the hospice care plan resolved, yet active orders still included a referral to a named hospice and a referral for evaluation and treatment for palliative care for pain management. These issues were confirmed on review by regional clinical leadership.
Incomplete and Inaccurate Clinical Records: Multiple residents had TAR entries showing identical vital signs and/or weights repeated over several consecutive days despite monthly monitoring orders. For one resident, the provider noted repeated BP readings that were exactly the same, and the DON stated the system was pulling prior results when staff did not enter new data; the surveyor confirmed the records were inaccurate.
A resident’s clinical record was found to be incomplete and inaccurate when staff documented pacemaker monitor checks on the TAR using a code indicating “drug not available,” which was inappropriate for this treatment and acknowledged as incorrect by the RN. In addition, a surveillance UA dip ordered to verify resolution of a UTI was signed off as completed, but no UA result was documented in the record or attached to the physician order, and the RN reported he performed the test but did not chart or file the machine-generated results.
A resident had a physician’s order for JP (Jackson Pratt) drain monitoring every shift for prophylaxis, but the Treatment Administration Record for one month showed multiple missing entries where this monitoring was not documented as completed on evening and night shifts. Record review identified specific shifts with no documentation of the ordered JP drain checks, and the DON confirmed these omissions during an interview with surveyors.
A resident who returned from surgery with a drain in place had the drain removed by nursing staff one day after arrival, despite orders for it to remain until a follow-up visit. Documentation did not include a written or verbal order from the medical provider authorizing the removal, and this omission was confirmed by the DON.
A resident's clinical record and care plan contained inaccurate information regarding the location of a venous ulcer for several months. Although treatment and physician notes consistently referenced the right lower leg, nursing documentation and the care plan incorrectly identified the left lower leg as the site of the wound. The error persisted through multiple care plan revisions and was confirmed by nursing staff during a record review.
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