Inaccurate Medical Record Documentation Due to Unauthorized Note Editing
Penalty
Summary
The facility failed to ensure that medical records for a resident were complete and accurately documented in accordance with accepted professional standards. Specifically, the Director of Nursing (DON) edited a progress note originally written by an LVN regarding wound care provided to a resident. The LVN's original note indicated that the previous dressing was dated three days prior to the wound care, suggesting a possible lapse in daily wound care. Five days after the original entry, the DON altered the note to remove the reference to the previous dressing date, despite not having performed the wound care herself. Interviews revealed that the LVN documented the date found on the dressing during the wound care and was unaware of why the DON changed her note. The DON admitted to editing the note because she perceived it as a red flag and suspected the LVN of falsifying documentation, but acknowledged that she should not have changed the note and should have addressed her concerns differently. Facility policy requires documentation to be concise, accurate, and complete, and the administrator confirmed the expectation for accurate records.