Incomplete and Inaccurate Medical Record Documentation for Two Residents
Penalty
Summary
The facility failed to maintain complete and accurate medical records for two residents. For one resident, the Nursing Weekly Summary (NWS) did not accurately reflect the actual condition of the resident's skin, toes, and toenails. Observations revealed significant issues such as dry and flaky skin, red and swollen toes, long and discolored toenails, wounds, and black debris between the toes. However, the NWS entries for several weeks either indicated no new skin issues, marked the skin section as not applicable, or stated the skin was clear and intact, which did not match the resident's observed condition. The Director of Nursing (DON) confirmed that the documentation was not accurate and did not reflect the true condition of the resident's skin and nails. Additionally, the same resident's Nursing Hemodialysis Communication Observation/Assessments (NHCOA) were not completed on multiple dates. The forms were missing critical information such as assessments of the dialysis access site, documentation of medications administered, pain levels, and post-dialysis assessments. In several instances, both pre- and post-dialysis sections were left blank, and the Dialysis Center documentation was incomplete. The DON stated that licensed nurses should complete these assessments before and after dialysis and that the Dialysis Center staff should also document following treatment, but this was not done. For another resident, the Initial Social History Assessment was started but not completed. The Social Services Director (SSD) acknowledged that the assessment was initiated but left unfinished. Facility policy requires the social services department to obtain pertinent social data related to the resident's illness and care, and documentation policies require clinical records to accurately reflect care provided to ensure continuity and coordination of services. These failures resulted in incomplete records for both residents.