Failure to Maintain Accurate Medical Records for Wound Care and Immunizations
Penalty
Summary
The facility failed to maintain complete and accurate medical records for residents, as evidenced by two separate incidents. In the first case, a resident receiving enteral feeding via a gastric tube had a split gauze dressing dated three days prior, despite physician orders and facility policy requiring daily dressing changes. Documentation in the Treatment Administration Record (TAR) indicated the dressing was changed on days that did not match the date on the gauze, and staff interviews revealed confusion regarding responsibility for performing and documenting the dressing change. The wound care nurse, LPNs, and Director of Nursing (DON) each provided differing accounts of who was responsible for the task and for recording it in the medical record, resulting in incomplete and inaccurate documentation of care provided. In the second incident, a resident's immunization records were incomplete and inconsistent. The resident's record showed receipt of an influenza vaccine and refusal of a pneumococcal vaccine, but the informed consent form for the influenza vaccine was signed by the resident without granting permission for administration. Additionally, there was no documented informed consent or declination form for the pneumococcal vaccine, despite the record indicating it was refused. The DON confirmed that the facility's process required signed consent or declination forms to be uploaded into the medical record, but was unable to locate the necessary documentation for the pneumococcal vaccine. Facility policies required that all treatments, services, and changes in resident condition be documented in the clinical record by the appropriate staff, and that informed consent or declination for vaccinations be properly recorded. The failure to accurately document wound care and immunization consent resulted in incomplete medical records for the residents involved.