Deficient Medical Record Documentation and Incomplete Medication and Wound Care Records
Penalty
Summary
Surveyors identified multiple deficiencies related to the maintenance of complete and accurate medical records for several residents. For one resident with behavioral monitoring orders, staff failed to document required observations as specified by the physician, instead marking an 'X' rather than indicating 'yes' or 'no' for the presence of behaviors, and did not provide corresponding progress notes when behaviors were observed. The Director of Nursing confirmed that the documentation was incomplete and did not follow the order's requirements. For two residents receiving medication management, there were errors in both the transcription and documentation of medication orders and administration. One resident's medication order was transcribed incorrectly, using the wrong symbol for a critical parameter, which was acknowledged by both the DON and an Advanced Practice Registered Nurse. Another resident had insulin doses held due to low blood sugar readings, but staff failed to document provider notification or the rationale for withholding the medication in the nurses' notes, as required by facility policy and standard practice. Additionally, for a resident requiring daily wound care, staff documented that care was provided on days when it was actually performed by another nurse, without verifying completion. The responsible nurse admitted to documenting care based on verbal reports rather than direct observation or confirmation, and a unit manager confirmed that documenting care not personally completed constitutes false documentation. Facility policy requires detailed documentation of wound care, including date, time, and wound appearance, which was not consistently followed.