Health inspection·November 8, 2023

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure complete and accurate documentation of medical records in accordance with accepted professional standards and practices for one of three sampled residents (Resident 1) when the Certified Nursing Assistants (CNA) did not complete accurate documentation for Resident 1 every two hour repositioning and truing schedule. This failure resulted in inaccurate documentation for Resident 1. Findings: During a review of Resident 1's, admission Record (AR) (AR-a record which contains resident personal information), the AR indicated, Resident 1 was a [AGE] year old female who was re-admitted to the Skilled Nursing Facility (SNF) on 10/14/22. Resident had a diagnosis of .hemiplegia (paralysis of one side of the body) and hemiparesis (weakness on side of the body) During a review of Resident 1 ' s care plan, dated 9/27/23, the care plan indicated .Focus .The resident has an [activities of daily living] self-care performance deficit [related to] Dementia (loss of thinking, remembering and reasoning) Disease Process, Fatigue, Musculoskeletal impairment .total dependent (dependent on others for all care needs) .Goal .Needs will be met .Interventions .Bed Mobility: The resident is total dependent on staff for repositioning and turning in bed every 2 hours and as needed . During a concurrent interview and record review on 11/2/23 at 4:45 p.m. with Certified Nursing Assistant (CNA) 4, Resident 1 ' s Turning and Repositioning dated September 2023 was reviewed. The Turning and Repositioning September 2023 indicated, there were missed documentation for Resident 1 turning and repositioning. CNA 4 stated, she worked PM shift (2 p.m. -10:30 p.m.) on 9/8/23, 9/9/23, 9/21/23 and 9/22/23.CNA 4 stated on 9/8/23, she did not document turning and reposition for Resident 1 every 2 hours. CNA 4 stated on 9/9/23, she did not document turning and repositioning every 2 hours for Resident 1. CNA 4 stated on 9/21/23, she did not document turning and repositioning every 2 hours for Resident 1. CNA 4 stated on 9/22/23, she did not document turning and repositioning every 2 hours for Resident 1. CNA 4 stated it is expected for staff to chart tasks as soon as possible once they have been completed. CNA 4 stated it was important for Resident 1 to be turned and repositioned every 2 hours to help maintain skin integrity because Resident 1 cannot reposition or turn herself. During a concurrent interview and record review on 11/2/23 at 5:03 p.m. with Certified Nursing Assistant (CNA) 5, Resident 1 ' s Turning and Repositioning dated September 2023 was reviewed. The Turning and Repositioning dated September 2023 indicated there was missed documentation for Resident 1 ' Page 1 of 2 055028 055028 11/08/2023 Los Banos Post Acute 931 Idaho Ave. Los Banos, CA 93635

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few s turning and repositioning. CNA 5 stated, turning and repositioning should be documented in Resident 1 ' s electronic record at least every two hours. CNA 5 stated staff were trained to document once the task was completed. During a concurrent interview and record review on 11/2/23 at 5:12 p.m. with CNA 6, Resident 1 ' s Turning and Repositioning dated September 2023 was reviewed. The Turning and Repositioning dated September 2023 indicated there was missed documentation for Resident 1 ' s turning and repositioning. CNA 6 stated turning and repositioning should be documented every two hours for Resident 1. CNA 6 stated documentation of Resident 1 Turing and Repositioning for the month of September 2023 had missed documentation. During an interview on 11/2/23 at 5:26 p.m. with Assistant Director of Nurses (ADON), the ADON stated Resident 1 ' s care plan interventions had missed documentation for September 2023. The ADON stated staff had been instructed on where and how often to document interventions for residents. The ADON stated staff did not document interventions. The ADON stated it is important to document interventions, to keep residents healthy and safe. The ADON stated there is missed documentation for Resident 1 ' s turning and reposition every two hours for September 2023. During a professional reference reviewed retrieved from https://bok.ahima.org/doc?oid=301868 titled, Ethical Standards for Clinical Documentation Imporvement (CDI) Professionals dated June 2016, the professional reference review indicated, .Ethical Standards .Facilitate accurate, complete, and consistent clinical documentation within the health record to demonstrate quality care, support coding and reporting of high-quality healthcare data used for both individual patients and aggregate reporting . During a professional reference reviewed retrieved from https://journals.lww.com/cns-journal/Fulltext/2014/11000/Quality_Nursing_Documentation_in_the_Medical.4.aspx titled Quality Nursing Documentation in the Medical Record, dated December 2014, the professional reference review indicated, .Current healthcare systems require that documentation ensures continuity of care, provides legal evidence of the process of care delivered by all disciplines, and supports evaluation of quality of patient care. Healthcare professionals should fully understand the principles of maintaining a legally sound health record .Documentation is regulated by both state and federal statutes. Poor standards of documentation have been linked to the failure to detect patients who were clinically deteriorating All providers of healthcare for the patient are responsible for knowing the required documentation and are held accountable for their entries and for missing information in the medical record . 055028 Page 2 of 2