Failure to Maintain Accurate and Timely Clinical Documentation
Penalty
Summary
The facility failed to maintain accurate and timely clinical records for two residents, resulting in deficiencies related to documentation standards. For one resident, the Occupational Therapy (OT) Progress Notes and Discharge Summary were not completed within the required timeframe. The OT Progress Report dated 2/24/2025 was signed and completed on 3/4/2025, and the OT Progress Report dated 3/3/2025, as well as the OT Discharge Summary dated 3/4/2025, were both signed and completed on 3/17/2025. The Director of Rehabilitation confirmed that these documents were completed very late and emphasized the importance of timely documentation for continuity of care and accurate communication among healthcare providers. The facility's policy required progress reports and discharge summaries to be completed within seven days, which was not followed in these instances. Another deficiency was identified in the medication administration documentation for a different resident. The Licensed Vocational Nurse (LVN) left medications at the resident's bedside for self-administration, and the resident did not take them at the scheduled time. The LVN later documented in the Medication Administration Record (MAR) that the medications were administered during the scheduled morning pass, even though the resident actually took them later. The LVN admitted to documenting the administration before the resident took the medications and acknowledged that the MAR did not accurately reflect the actual time of administration. The Director of Nursing confirmed that the MAR should accurately document the time medications are given, as it is used by staff and physicians to track medication administration. Both deficiencies were confirmed through interviews, record reviews, and observations. The facility's policies and procedures for clinical documentation and medication administration were not followed, resulting in inaccurate and untimely records. These lapses in documentation could lead to miscommunication among staff and incomplete information regarding the care and services provided to residents.