Inaccurate Medical Record Documentation After Resident Discharge
Penalty
Summary
The facility failed to maintain accurate medical records for one of eight sampled residents. Specifically, a review of the closed medical record for a resident who had been discharged revealed that multiple care tasks and medication administrations were documented as completed on the medication administration record (MAR) for a date after the resident had already left the facility. These tasks included daily use of heel protectors, monitoring of apical pulse and pacemaker site, observation for pacemaker malfunction, and administration of potassium chloride ER tablets. Both the LVN and the DON confirmed that the MAR indicated these tasks as completed after the resident's discharge, and the facility's policy required clinical records to be a concise and accurate account of care and treatment provided.