Inaccurate Medical Record Documentation Due to Copy-Paste Error
Penalty
Summary
The facility failed to ensure the accuracy of medical records for one resident. Review of the clinical record for a resident with multiple diagnoses, including vascular dementia, hemiplegia, neurogenic bladder, chronic respiratory failure, and calorie malnutrition, showed inconsistencies in documentation regarding the presence of wounds. The quarterly Minimum Data Set assessment indicated the resident did not have any unhealed pressure ulcers or injuries, and nursing notes confirmed the resident was at high risk for impaired skin integrity but maintained skin integrity with preventative care. However, Nurse Practitioner notes on several dates documented that the resident had current wounds, which was inconsistent with other clinical documentation and staff interviews. During interviews, the wound LPN confirmed the resident did not have any wounds or skin impairment at the time, and both the DON and the Nurse Practitioner verified that the notes indicating wounds were inaccurate. The Nurse Practitioner admitted to copying and pasting information from another entry without making necessary revisions, resulting in erroneous documentation in the resident's medical record.