Incomplete and Inaccurate Medical Record Documentation
Penalty
Summary
The facility failed to maintain complete and accurate medical records for a resident, as required by accepted professional standards. Specifically, an LVN documented a 72-hour change in condition (CIC) monitoring with an incorrect date, recording the monitoring before the actual CIC event occurred. Additionally, CNAs did not consistently document the resident's percentage of food intake for each meal, with several instances of missing entries for breakfast, lunch, or dinner. There were also inaccuracies in the documentation of the resident's bladder continence, with multiple shifts failing to record the required information. The resident involved had diagnoses including Guillain-Barre syndrome, age-related osteoporosis, and essential hypertension, and was noted to have intact cognition. During interviews and record reviews, both an RN and the DON confirmed that the documentation for bladder continence and nutritional intake was incomplete and inaccurate. The facility's own policy required objective observations and progress toward care plan goals to be documented, but these standards were not met in this case.