Failure to Accurately Document Resident Incident and Maintain Medical Records
Penalty
Summary
Facility staff failed to maintain accurate and complete medical records for two residents when documentation regarding an incident of inappropriate touching was falsified. Specifically, a charge nurse was instructed by the administrator to document that a resident had inappropriate behavior toward staff, rather than accurately recording that the behavior was directed toward another resident. The charge nurse initially disagreed with this directive but ultimately completed the SBAR form as instructed, misrepresenting the facts of the incident. The MDS nurse subsequently developed a care plan based on this inaccurate information, indicating that the resident had inappropriate behavior with staff instead of the actual victim. The incident involved two residents, both with cognitive impairments and requiring varying levels of assistance with daily activities. One resident, with a history of depressive disorder, schizophrenia, and psychosis, reported feeling unsafe after being touched inappropriately by another resident with dementia and anxiety disorder. The affected resident expressed discomfort and a lack of safety due to the incident, which was only discussed with the charge nurse and not properly documented in the medical record as required. Multiple staff interviews confirmed that the administrator directed the documentation to be falsified to avoid reporting the incident to the state health department and to justify a psychiatric evaluation for the resident who exhibited the inappropriate behavior. As a result, the social services director was unable to assess the affected resident, and the care plan did not reflect the true nature of the incident. Facility policy requires that documentation be objective, complete, and accurate, and that the administrator is responsible for ensuring compliance with these standards.