109.21 Principle
Written nursing care and
administrative policies and procedures
shall be developed to provide the
nursing staff with methods of meeting
its responsibilities and achieving
goals.
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Observations:
Based on review of facility documents, and staff interview (EMP), it was determined that facility staff failed to follow the facility approved protocols for Interdisciplinary Documentation and Charting Policy according to physician orders for four medical records (MR1, MR2, MR3, MR4).
On March 6, 2026, review of facility policy "Interdisciplinary Documentation and Charting" last revised effective January 1, 2025, revealed "Policy Purpose: To establish a consistent approach for documenting clinical data utilizing e-Health and the Clinical Practice Model framework ... Procedure: ... B. Charting Clinical Data (General Information): 1. Patient data/Clinical information is to be recorded in e-Health. a. In real-time or as close to real-time as possible. b. As often as the patient's condition warrants to maximize communication between caregivers. ... (1) Patient Care Summary (PCS): (a) A comprehensive examination/assessment (Head to Toe Assessment) of the patient will be performed and documented on the PCS upon admission by Nursing. Thereafter, the PCS shall be used to document all physical assessment and interventions related to assessments. Assessments are completed per the following and repeated at a frequency based on the acuity and needs of the patient. ... 3) The assessment includes all ongoing screens (Pain, Fall Risk, Braden, Nutrition, and Functional). When prompted (due to scoring threshold, criteria), initiate appropriate actions."
Review of facility document on March 6, 2026, reveal on February 3-4, 2026, MR1 was ordered to be assessed every four (4) hours. Nursing documentation due on February 3, 2026, at 8:00 pm was completed at 10:16 pm and the next documentation completed for MR1 was completed at 7:26 am, nine (9) hours later. Following the 7:26 am documentation MR1 was documented at 6:51 pm, 11 hours later.
Review of facility document on March 6, 2026, reveal on February 9, 2026, MR2 was ordered to be assessed every four (4) hours. Nursing documentation due on February 9, 2026, at 4:00 am, was completed at 4:41 am, and next documentation completed for MR2 was completed at 3:37pm, 11 hours later.
Review of facility document on March 6, 2026, reveal on February 9, 2026, MR3 was ordered to be assessed every four (4) hours. Nursing documentation due on February 9, 2026, at 4:00 am, was completed at 4:39 am, and next documentation completed for MR3 was completed at 6:30 pm, 14 hours later.
Review of facility document on March 6, 2026, reveal on February 23, 2026, MR4 was ordered to be assessed every four (4) hours. Nursing documentation due on February 23, 2026, at 12:00 pm was completed at 6:32 pm, 6.5 hours later. Additional documentation ordered for every (4) four hours for MR4 was due at 4:00 am, was completed at 6:14 am and the next documentation completed for MR4 was completed at 4:06 pm, 10 hours later.
Interview with EMP1 on March 6, 2026, EMP1 confirmed all information above is complete and accurate.
| | Plan of Correction - To be completed: 05/08/2026
Action Step: Executive responsible for oversight of Plan of Correction
Responsible Party: Chief Nursing Officer
Completion Date: March 11, 2026
Action Step: Revise Interdisciplinary Documentation and Charting Policy to reflect expected time (by the end of shift) when nursing documentation to occur
Responsible Party: Director of Nursing
Completion Date: March 24, 2026
Action Step: Re-educate Registered Nursing staff to revised Interdisciplinary Documentation and Charting Policy and importance of following provider orders
Responsible Party: 5 Lime Nurse Manager
Completion Date: May 1, 2026
Action Step:- Audit a 24 hour period on 10 charts per week to ensure nursing documentation timing is within the guidelines of the policy and per doctor's orders with a goal of 100% compliance. Incidence of non compliance will result in re-education.
Responsible Party: 5 Lime Nurse Manager
Completion Date: May 8, 2026
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