Incomplete and Inaccurate Clinical Record Documentation
Penalty
Summary
The facility failed to ensure that clinical records were complete and accurate for two residents. For one resident, there was a physician's order for nightly use of a CPAP device, but the Treatment Administration Record (TAR) showed the device was applied on several dates when, in fact, the CPAP was missing necessary parts and could not be used. Documentation in the clinical record confirmed the device was not functional until a missing part was received, yet staff had inaccurately documented its application prior to that date. For another resident, the Medication Administration Record (MAR) listed medications as being prescribed for Parkinson's disease and psychosis, but the resident's active diagnosis list did not include these conditions. Provider notes clarified that the medications were actually prescribed for drug-induced tremor and bipolar disorder. During a review with the Director of Nursing, it was confirmed that the MAR contained inaccurate information regarding the indications for the prescribed medications.