Inaccurate Documentation of Cholecystostomy Dressing Changes
Penalty
Summary
The facility failed to maintain a complete and accurate medical record for a resident receiving cholecystostomy care. Documentation on the Medication Administration Record (MAR) indicated that two nurses had changed the resident's cholecystostomy dressing at scheduled times, but both nurses later confirmed they had not performed the dressing change. One nurse documented the care as completed despite not providing it, while the other nurse recorded that the dressing was changed by the Wound Nurse, but was unsure how to properly document care provided by another nurse and could not recall the Wound Nurse's name. Additionally, the Treatment Administration Record (TAR) showed the Wound Nurse had documented dressing changes on subsequent days, but the Wound Nurse admitted to recording the care as completed based on information from a nurse aide, without verifying that the dressing change had actually occurred. Further investigation revealed that the nurse aide had assumed the dressing was changed after hearing a nurse mention taking care of the sutures, but the nurse only inspected the site and did not perform a dressing change. The Wound Nurse did not confirm with the nurse or check the dressing before documenting the care. The Director of Nursing confirmed that documentation should only reflect care that was actually provided and that staff should not record care they did not perform. These actions resulted in inaccurate and incomplete medical records for the resident's cholecystostomy care.