MOUNTAIN PARK SENIOR LIVING

Based on record review and interview, the manager failed to ensure a caregiver documented the services provided to a resident in the resident's medical record, for one of five sampled residents.

Findings Include:

1. A review of R5's medical record revealed a service plan dated February 11, 2023, which reflected "7. Morning and Night Care: Physical Assist, Resident requires physical assistance with walking and getting out of bed RA assistant two times per day every day...9. Bathing resident requires physical assistance with participation by the resident to complete task one time per day every one week on Monday and Thursday...16. Wellness Checks- Daily by resident assistant one time per day every day at 6:00am". R5's record also contained a document titled "Monthly Task Log" which reflected "TNC (task not completed)" from April 1, 2023 through April 30, 2023 for shaving assistance, monthly vitals, wellness checks, and bathing physical assistance.

2. In an interview, E1 reported all aforementioned services in R5's service plan were provided. E1 reviewed R5's service plan and monthly task log and acknowledged the services were not documented as provided.

Based on record review and interview, the manager failed to ensure an entry in a resident's medical record was authenticated, for two of five residents sampled. The deficient practice posed a risk as the Department was unable to ensure the facility's compliance.

Findings include:

1. Arizona Administrative Code (A.A.C.) R9-10-101(26) states "Authenticate" means: "to establish authorship of a document or an entry in a medical record by: a. A written signature; b. An individual's initials, if the individual's written signature appears on the document or in the medical record; c. A rubber-stamp signature; or d. An electronic signature code."

2. A review of R2's medical record revealed a service plan dated March 29, 2023 which reflected "Resident performs Grooming/Personal Hygiene but requires physical assistances to complete the task...and will be provided assistance two time per day, every day, any time during shift." R2's medical record also contained a document titled "Monthly Task Log" which reflected "INF" (information only) from April 1, 2023 to April 30, 2023 for "Grooming/Personal Hygiene". However, the entries did not reflect the initials or signature(s) of the individual who made the entries.

3. A review of R5's medical record revealed a service plan dated February 11, 2023, which reflected "Skin Maintenance, RA, assistance will be provided three times per day... level of assistance - Grooming/personal Hygiene: total". R5's record also contained a document titled "Monthly Task Log" which reflected "INF" from April 1, 2023 to April 30, 2023 for skin maintenance and dressing. However, the entries did not reflect the initials or signature(s) of the individual who made the entries.

4. In an interview, E1 reviewed R2's and R5's documentation and acknowledged the entries in the medical records were not authenticated.