Failure to Maintain Accurate and Complete Medical Records and Documentation
Penalty
Summary
The facility failed to ensure the accuracy and clarity of medical records for two residents, resulting in deficiencies related to documentation and communication of care. For one resident with a history of a right femur fracture and abnormal gait, the medical record contained two active, conflicting physician's orders regarding the weight-bearing status of the right leg. One order indicated weight bearing as tolerated, while a subsequent order required non-weight bearing due to a wound on the right heel. Both orders remained active in the record, causing confusion among staff about the correct precautions to follow. Interviews with nursing and rehabilitation staff confirmed the presence of conflicting orders and acknowledged the importance of discontinuing outdated orders to prevent miscommunication and inappropriate care. Another resident, admitted with diagnoses including congestive heart failure, major depressive disorder, dementia, and post-traumatic stress disorder, was receiving Restorative Nursing Aide (RNA) services as ordered for passive range of motion, mobility exercises, and splint application. However, the documentation in the Restorative Nursing Weekly/Monthly Progress Reports was incomplete and lacked critical details such as the number of repetitions, resistance, speed, and average time spent per day on each intervention. Although RNA staff indicated that services were being provided and referenced other forms, the required documentation on the official progress reports was missing or unclear. This incomplete documentation failed to accurately reflect the services provided and could lead to gaps in care continuity. Facility policy required that all services, progress toward care plan goals, and changes in resident condition be documented objectively, completely, and accurately in the medical record. Staff interviews confirmed the expectation for clear and accurate documentation and acknowledged that incomplete records could result in an inaccurate reflection of care and services provided. The deficiencies identified were based on direct observation, record review, and staff interviews, and were consistent with the facility's own policies regarding charting and documentation.