Inaccurate Medical Record Documentation
Penalty
Summary
The facility failed to ensure the accuracy of medical records for a resident, as evidenced by a discrepancy in the Nurses' Progress Note. The note inaccurately documented that the resident was COVID-19 positive and receiving treatment with a Z pack, while in reality, the resident was COVID-19 negative and not receiving such medication. This inaccuracy was confirmed during interviews with the Director of Nursing and a Licensed Practical Nurse, who both stated that the resident did not have COVID-19 and was not on the mentioned medication. The facility's Charting and Documentation Policy requires that all services provided to residents and any changes in their medical or mental condition be accurately documented in their medical records. However, the review of the resident's records revealed a failure to adhere to this policy, as the progress note contained incorrect information about the resident's COVID-19 status and treatment. This error was not corrected in the medical record, which is a violation of the facility's policy on maintaining accurate medical records. The resident involved had a severe cognitive impairment, as indicated by a Brief Interview of Mental Status score of 00, and required dependent assistance for activities of daily living. The inaccurate documentation in the resident's medical record has the potential to affect the care and treatment provided to the resident, as well as other residents in the facility, by leading to inappropriate precautions or treatments based on incorrect information.
Plan Of Correction
F-842 Resident Records- identifiable Information 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 patents 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 and ongoing. Example of Error identified was presented and discussed. Thereafter, DON has an ongoing QAPI Plan for incorrect documentation Audit Tool. This was started on as 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.