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Staff interviews revealed that staff are not aware of the ability to change or edit reports made by others. Staff 4 stated "I am not sure if I can change notes" in reference to computer administrator privileges. Staff 2 (S2) had never heard of any instances where the notes were changed or edited after they were entered into the computer system. Staff 1 (S1) stated there were times they were sure that they had charted very specific instances in resident's care notes to discover at a later date they were not there.
LPA Observations revealed during a demonstration of the computer charting system, Staff 4 (S4) was able to edit the notes originating from another staff member. The edit did not include a time stamp or a record of the edit from S4. S4 was able to demonstrate for the LPA that someone with the right administrative access would be able to change notes by adding or removing text.
Based on interviews, direct LPA observations and records review, a preponderance of evidence does not exist to prove that the alleged violation occurred, therefore the allegation is UNSUBSTANTIATED. An exit interview was conducted with Scottie Geno, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided. |