Inaccurate Medical Records for Resident
Penalty
Summary
The facility failed to maintain accurate medical records for a resident, as required by professional standards and practices. The deficiency was identified when a Nurses' Progress Note inaccurately documented that the resident was COVID-19 positive and receiving treatment with a Z pack, despite the resident being COVID-19 negative and not receiving such medication. This discrepancy was confirmed through interviews with the Director of Nursing and a Licensed Practical Nurse, both of whom stated that the resident did not have COVID-19 and was not receiving the mentioned treatment. The resident in question had a severe mental status as indicated by a Brief Interview of Mental Status Summary Score of 00, requiring dependent assistance for activities of daily living. The resident's demographic sheet and Minimum Data Set Quarterly Assessment were reviewed, revealing diagnoses including protein-calorie malnutrition and atherosclerotic conditions. Despite these documented conditions, the medical records inaccurately reflected the resident's COVID-19 status and treatment, which could potentially affect the care provided. The facility's policies on charting and documentation, as well as charting errors and omissions, were reviewed. These policies require that all services and changes in a resident's condition be accurately documented by licensed personnel. However, the inaccurate entry in the resident's medical record was not corrected, highlighting a failure to adhere to these policies. This inaccuracy in medical records has the potential to impact the care of any resident within the facility.
Plan Of Correction
N101-FAC Resident Medical Records Identify patients that were at risk and what did: Once identified by surveyor regarding Resident #33, the Director of Nursing contacted the LPN that erroneously documented that the patient was COVID positive when he was not and was asked to clarify the note. This was done on How will you identify other patients that are at risk: The LPN received a 1:1 training on Accurate Documentation. An audit was done on all remaining residents with diagnosis to ensure that the documentation was correct. Measures put in Place: An inservice was done for all Nurses on Resident Records - Identifiable Information and Resident Accuracy was started for all nurses on an ongoing basis. Example of Error identified was presented and discussed. Thereafter, the DON has an ongoing QAPI Plan for incorrect documentation Audit Tool. This was started on a weekly review. How will you monitor: The DON and/or designee will be responsible for bringing the findings and summary to the QAPI Committee. This will occur monthly for 3 months, then quarterly and/or if any variances are reported ongoing.