Incomplete and Inaccurate Clinical Record Documentation
Penalty
Summary
The facility failed to ensure that clinical records for four of six reviewed residents were complete and accurate, as required by professional standards. For one resident with severe cognitive impairment and a history of Alzheimer’s disease and seizures, documentation was missing for two shifts during a 72-hour monitoring period following a physical altercation. The responsible LVN confirmed that the absence of progress notes meant staff would not be aware of any changes in the resident’s condition during those times. Another resident with mild cognitive impairment and multiple chronic conditions, including hypertension and chronic kidney disease, had a blank Medication Administration Record (MAR) for one shift, indicating that medications may not have been administered or documented. The RN acknowledged that licensed nurses are responsible for ensuring MARs are completed. Similarly, a third resident with severe cognitive impairment and chronic kidney disease was missing documentation for the final shift of a 72-hour monitoring period after a physical altercation, as confirmed by the LVN. A fourth resident, who was dependent on hemodialysis and had no cognitive impairment, had a blank MAR for one shift, suggesting medications were not given, and lacked documentation in the progress notes upon return from dialysis. The RN stated that documentation is required to note any changes in the resident’s status after dialysis, and the facility’s policy mandates recording pre- and post-dialysis information. The facility’s documentation guidelines require prompt, complete, and accurate recording of resident care, which was not followed in these instances.