Inaccurate Medical Record Documentation for Pressure Relief and Blood Pressure Monitoring
Penalty
Summary
The facility failed to maintain accurate and complete medical records for three residents. For one resident with severe cognitive deficits and a high risk for pressure ulcers, nursing staff documented in the Treatment Administration Record (TAR) that a Prevalon boot was applied to the right foot as ordered by the physician. However, multiple observations over several days showed the resident was not wearing the boot, and it was not present in the room. The medical record also lacked documentation of any refusal by the resident to wear the boot, despite an active physician order requiring its use at all times except for hygiene or care. For two other residents with end stage renal disease and dialysis fistulas in the left arm, the facility failed to accurately document the location of blood pressure (BP) readings. Both residents had physician orders and care plans specifying that no BP readings or blood draws should be performed on the left arm. Despite this, the electronic medical record indicated that BP readings were documented as being taken from the left arm on multiple occasions. Interviews with the residents and staff confirmed that the left arm was not actually used, and staff attributed the entries to documentation errors. The facility's own policy requires that documentation in the medical record be factual, objective, accurate, and detailed enough to reflect the resident's care and response. In these cases, the records did not accurately represent the care provided or the residents' experiences, as required by facility policy and professional standards.