Failure to Use Standard Medical Terminology in Resident Documentation
Penalty
Summary
The facility failed to maintain and complete accurate and appropriate documentation in the medical records for two residents. For one resident, the clinical record included nutrition progress notes that used non-standard abbreviations such as 'Gr X' and 'Gr 3' to describe pressure injuries, and 'bmf' to refer to between meal feedings. These terms were not recognized as acceptable medical terminology. The resident had diagnoses including high blood pressure, cerebrovascular accident, and muscle weakness, and was documented as having a stage three pressure injury to the coccyx and an unstageable pressure injury to the left ankle. For the second resident, the clinical record also contained a nutrition progress note using the term 'Gr2' to describe a stage two pressure injury. This resident had diagnoses of high blood pressure, dementia, and difficulty swallowing, and was documented as having a stage two pressure injury and an unstageable pressure injury to the coccyx. During staff interviews, the registered dietitian confirmed the use of these non-standard terms, and the assistant director of nursing acknowledged that such terminology does not meet acceptable standards of practice, resulting in incomplete and inaccurate documentation in the medical records.