Inaccurate Documentation of Hearing Aid Application in Medical Record
Penalty
No penalty information released
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Summary
The facility failed to ensure the accuracy of a resident's medical record regarding the application of a hearing aid. Review of the Treatment Administration Record (TAR) and Medication Administration Record (MAR) for one resident showed documentation indicating the resident's right hearing aid was applied on multiple dates. However, a nurse who documented these entries stated during interviews that she had never seen the resident with hearing aids and acknowledged that any indication she had applied the hearing aid was a mistake. Both the Director of Nursing and the Administrator confirmed that staff should not document tasks as completed if they were not actually performed.