Incomplete and Inaccurate Medical Record Documentation for Two Residents
Penalty
Summary
The facility failed to maintain complete and accurate medical records for two residents by not documenting the actual times of change of condition (COC) events, notifications to representatives and physicians, and the care provided following these events. For one resident, documentation was missing regarding the time an ice pack was applied after an altercation and the time pain medication was refused. Additionally, the Social Services Director did not document required psychosocial evaluations on specific days following the resident's return from the hospital, and the COC evaluation contained inaccurate times for when the physician and representative were notified, with entries recorded before the incident occurred. For the second resident, the facility did not document observed behaviors and interventions as required by the care plan and physician orders. The COC evaluation for this resident also contained inaccurate times for notifications, and there was no documentation of behavioral monitoring or interventions in the Medication Administration Record (MAR) for incidents of aggression. The resident's refusal to be assessed after an altercation was noted, but the required documentation of behaviors and interventions was incomplete. Interviews with nursing staff and the Director of Nursing confirmed that documentation was not completed promptly or accurately, and that entries were sometimes made hours after events or with incorrect times. The facility's own policy requires prompt, complete, and accurate documentation, and prohibits documenting events before they occur. The failure to follow these standards resulted in incomplete and inaccurate medical records for both residents.