Inaccurate Medical Record Documentation for Respiratory and Enteral Care
Penalty
Summary
The facility failed to maintain accurate medical records for two residents. For one resident with severe cognitive impairment and ventilator dependence, the respiratory administration record indicated that ventilator tubing was changed on specific dates, but observation revealed the tubing had not been changed as documented. The respiratory therapist stated that tubing changes occurred weekly on Sundays, which did not align with the documentation. The Director of Nursing confirmed that documentation should only reflect actual changes performed according to physician orders. For another resident who was cognitively intact and dependent on staff for all activities of daily living, there were conflicting physician orders for enteral feeding times. The medication administration record showed that nurses signed off on both conflicting orders over several days, indicating inaccurate recordkeeping regarding the timing of tube feedings. The Director of Nursing acknowledged that only one time frame should have been documented, and the presence of conflicting orders led to inaccurate documentation.