Incomplete and Inaccurate Medical Record Documentation
Penalty
Summary
The facility failed to ensure that medical records were complete and accurately documented for two residents. For one resident, there was a discrepancy between the active physician order for showers, which specified Tuesdays and Fridays, and the kardex task, which indicated Mondays and Thursdays. The Director of Nursing confirmed that the kardex should reflect the physician's order, but this was not the case. For another resident who was bed-bound with limited range of motion and had received PT and OT services for contracture management, the discharge recommendations from OT included daily application and nightly removal of splints by nursing staff. However, there were no orders placed in the medical record for nursing to carry out these recommendations, nor were the recommendations reflected in the care plan. Interviews with the Director of Rehab and OT staff revealed that the orders were never entered into the EMR, and there was confusion regarding responsibility for entering such orders.