Failure to Maintain Accurate and Thorough Medical Records
Penalty
Summary
The facility failed to ensure the accuracy and thoroughness of documentation in resident medical records, as evidenced by findings in two residents' records. For one resident with multiple complex diagnoses, including end stage renal disease and a stage four pressure wound, there were conflicting and outdated wound care orders in the medical record. Staff continued to sign off on orders for suture monitoring even after documentation from a surgical follow-up indicated the sutures had been removed. Additionally, two different wound care orders were active simultaneously, and both were being marked as completed, despite not matching the current clinical situation. The facility's policy required nursing staff to follow provider orders, but this was not consistently done. In another case, a resident's code status was changed in the physician's orders to Do Not Resuscitate Comfort Care Arrest (DNR CC A) without any documentation of a discussion or agreement from the resident, who was cognitively intact and had previously expressed a desire to remain full code. The care plan and progress notes did not reflect any conversation or consent regarding the change in code status. The facility's policy required that discussions and decisions about advance directives be documented in the medical record, but this was not followed.