Inaccurate Physician Documentation of Gastrostomy Status
Penalty
Summary
The facility failed to ensure accurate completion of physician notes regarding the assessment and gastrostomy status of a resident, identified as R98. The resident was admitted with diagnoses including Alzheimer's disease, dysphagia, and gastric ulcer. However, the physician's notes inaccurately documented the presence of a gastrostomy and the need to monitor gastrostomy feeding over several months. Upon review, there were no physician orders for enteral feeds or gastrostomy care, and observations confirmed the absence of any gastrostomy equipment or site. Interviews with the resident's care nurse and the attending physician revealed that the resident never had a feeding tube and was on a pureed diet. The physician admitted to an error in documentation, confusing the resident with another patient who had a similar last name and a gastrostomy. This error led to incorrect documentation in the resident's clinical records, violating the requirement for accurate and complete clinical records as per 28 Pa. Code 211.5(f).
Plan Of Correction
Resident R98 physician notes have been corrected to reflect no gastrostomy tube. NPE / DON / Designee to re-educate facility physicians and Advanced Practice Providers regarding accuracy of documentation and diagnosis in physician/provider notes. Medical Records to complete weekly audits X 4 then monthly X 2 on 5 random residents physician notes and diagnoses to ensure accuracy of gastrostomy tube documentation. Medical Records will report the findings of the audits to the QAPI Committee X 3 months.