Failure to Maintain Accurate and Timely Medical Records for Residents
Penalty
Summary
The facility failed to maintain accurate and timely medical records for three residents, resulting in incomplete or delayed documentation of care and assessments. For one resident with moderate cognitive deficits, an indwelling urinary catheter, and a feeding tube, the care plan required catheter care every shift. However, the Medication Administration Record indicated that a catheter flush was not completed as scheduled, and a late nursing note was entered stating the flush was done with normal saline after the fact, based on an assumption rather than direct observation or confirmation. The Director of Nursing confirmed that the documentation was entered the next day without certainty that the procedure had been performed. Two other residents receiving dialysis also had deficiencies in their medical records. For both, Dialysis Evaluation forms were completed and entered into the system up to 12 days after the actual assessment dates. Additionally, the documentation referenced vital signs that were either missing or not recorded at the times indicated. For example, one resident's evaluation referenced vital signs that were not present in the record for the specified date and time, and another had only partial vital sign documentation that did not match the times noted in the assessment. Staff interviews and record reviews confirmed that the facility's documentation practices did not align with its own policy, which requires objective, complete, and accurate records of care, including the date and time procedures and treatments are provided. The lack of timely and accurate documentation for these residents, particularly those with complex medical needs such as dialysis and indwelling catheters, constituted a failure to safeguard resident-identifiable information and maintain medical records in accordance with accepted professional standards.