Inaccurate Clinical Documentation for a Resident
Penalty
Summary
The facility failed to ensure that clinical records were complete and accurately documented for one of the residents reviewed. Specifically, a quarterly Minimum Data Set (MDS) assessment for the resident indicated that the resident was sometimes understood and able to sometimes understand others, and was dependent on staff for personal hygiene care. However, discrepancies were found in the nursing notes related to the resident's care. A nursing note dated April 2, 2025, incorrectly documented that a straight catheterization was attempted three times without success. An interview with the Director of Nursing later revealed that this procedure was not attempted on the resident, and the note was mistakenly placed in the wrong chart. This error highlights a failure in maintaining accurate and complete clinical records for the resident, as required by regulatory standards.
Plan Of Correction
Resident #2 medical recorded updated marked progress note as invalid for incorrect documentation. To identify residents who have the potential to be affected, the Director Nursing/Designee will complete a review of nursing progress notes for the past 30 days to ensure that documentation is correct and accurate. To prevent recurrence, the licensed nursing staff will be educated on accurate and timely documentation of the medical record. To maintain and monitor compliance, the Director of Nursing/ designee will review progress notes of 5 residents weekly x's 4 weeks and monthly x's 2. Step 4: To maintain and monitor compliance, the Director of Nursing/ designee will review progress notes of 5 residents weekly x's 4 weeks and monthly x's 2.