Incomplete and Inaccurate Electronic Medical Records for Two Residents
Penalty
Summary
The facility failed to maintain complete and accurate electronic medical records for two residents, as evidenced by missing documentation of Activities of Daily Living (ADL) care and incomplete records regarding a resident's transfer and medication administration. One resident, who was alert and cognitively intact, reported not receiving a shower since admission and agreed their nails were long. Review of their clinical record showed no documentation of shower, bathing, or nail care in the electronic task records, nor was there any care plan documentation addressing these ADL needs. The Director of Nursing confirmed that a glitch prevented proper recording of these services and that the resident's preference for bed baths was not documented in the appropriate section. Another resident's record lacked critical information following an incident where the resident called 911 and was transferred to the hospital after making suicidal statements. The clinical record did not indicate the time of return to the facility, nor did it contain hospital or EMS records specifying the hospital destination or any accompanying documents. Additionally, the Medication Administration Record (MAR) showed that several medications were not administered on the day of the incident, with hold times noted but no further explanation or documentation regarding the missed doses. Interviews with nursing staff and the DON revealed a lack of recall regarding the resident's return time and medication administration, and the DON acknowledged that documents often do not return with residents from the emergency room. The facility's own policy requires that electronic medical records include comprehensive documentation such as physician orders, medication records, care plans, and scanned hospital documents, but these requirements were not met in the cases reviewed.