Failure to Maintain Accurate and Timely Medical Records for Resident Care
Penalty
Summary
The facility failed to maintain timely and accurate medical records in accordance with accepted professional standards for two residents. For one resident with a history of hypertension, hyperlipidemia, depression, and neuromuscular bladder dysfunction, there was an active physician order for urinary catheter care every shift. On one occasion, the assigned LVN provided urinary catheter care in the morning but failed to document the care at the time it was provided. The care was later documented in the electronic treatment administration record several hours after the actual provision of care, resulting in an inaccurate record of when the care was performed. Both the LVN and the Director of Nursing acknowledged that this inaccuracy could lead to confusion for subsequent shifts and did not reflect the care as ordered by the physician. For another resident with diagnoses including hemiplegia, dysphagia, muscle weakness, contracture, and dementia, there were physician orders and care plans for the application of a left resting hand splint and left elbow extension splint, as well as passive range of motion (PROM) exercises. Observations and interviews confirmed that the restorative nursing assistant performed PROM and applied the splints as ordered. However, the documentation in the RNA Documentation Survey Report inaccurately indicated that splints were applied to both arms, when in fact only the left arm required splinting. The Assistant Director of Nursing confirmed that the documentation was inaccurate for the dates reviewed and emphasized the importance of accurate records to reflect the care provided. The facility's policy and procedure on charting and documentation required that all treatments and services performed be documented objectively, completely, and accurately, including the date and time of the procedure or treatment. In both cases, the failure to document care accurately and in a timely manner resulted in medical records that did not reflect the actual care provided, as required by facility policy and professional standards.