Incomplete and Inaccurate Medical Record Documentation for Multiple Residents
Penalty
Summary
The facility failed to ensure that medical records were complete and accurate for four residents, as evidenced by multiple documentation errors and discrepancies. For one resident with acute respiratory failure and diabetes, the physician's order for continuous oxygen was incorrectly transcribed and implemented as PRN, yet nursing staff documented continuous oxygen administration on the MAR, despite the resident not using oxygen during multiple observations and interviews. The DON and unit manager confirmed the order was transcribed in error and that documentation did not reflect actual care provided. Another resident with end stage renal disease and an arteriovenous fistula had a physician's order specifying that blood pressure should not be taken on the right arm. However, multiple entries in the medical record indicated that blood pressure was taken on the right arm, while the MAR documented it as being taken on the left arm. The DON and unit manager acknowledged that nurses should not document blood pressures on the left arm when they were actually taken on the right arm. A third resident with epilepsy had an order for seizure pads to be placed on both side rails and checked every shift. Observations revealed only one seizure pad in place, yet staff documented in the TAR that both pads were present. Similarly, a fourth resident with multiple deep tissue injuries had an order for an air mattress to be set according to weight, but observations showed the mattress was set incorrectly, while documentation indicated it was set per order. In both cases, the DON and unit managers confirmed that documentation did not accurately reflect the care provided.