Inaccurate Documentation of CPAP Cleaning
Penalty
Summary
The facility failed to ensure that medical records were accurately documented and maintained in accordance with professional standards for one resident. The facility's policy requires concise, accurate, and complete documentation of assessments, interventions, and treatments. A review of a resident's medical record showed a physician's order for daily cleaning of a CPAP/BIPAP mask and tubing, which was documented as completed on the Medication Administration Record (MAR) for a specific date. However, direct observation of the resident's CPAP mask on that date revealed brown residue and beard hairs inside the mask, indicating it had not been cleaned as required. Further investigation included an interview with an LPN who admitted to documenting the cleaning of the CPAP mask before actually performing the task, stating that she was allowed to document tasks as complete even if they had not yet been done. The Director of Nursing later clarified that nurses were not permitted to document completion of tasks prior to actually completing them. This discrepancy between documentation and actual care provided led to the deficiency cited in the report.