Inaccurate and Incomplete Medical Record Documentation
Penalty
Summary
The facility failed to maintain complete and accurate medical records for several residents, resulting in multiple documentation errors. For one resident, the electronic health record (EHR) contained another individual's PASRR Level 1 screening, which was verified by the Assistant Director of Nursing (ADON) as an upload error. Additionally, the facility's Medication Administration Records (MAR) for two residents contained inaccurate documentation regarding monitoring for side effects of apixaban, an anticoagulant. The MARs indicated changes in condition that were not supported by corresponding progress notes, and the ADON confirmed these were typographical errors made by the same licensed vocational nurse (LVN), with no actual changes in condition reported or observed. Another resident's facesheet inaccurately listed a diagnosis of unspecified schizoaffective disorder, despite no supporting documentation in the history and physical examination, no related medications prescribed, and no evidence from the acute care hospital discharge records. The MDS coordinator clarified that this diagnosis was likely entered in error by a previous staff member and was not an active diagnosis for the resident. Furthermore, a review of a different resident's Physician Orders for Life-Sustaining Treatment (POLST) indicated the presence of an advance directive, but no such document was found in the medical record. The social services director (SSD) confirmed that the resident did not have an advance directive and acknowledged the POLST should have been updated to reflect this. Finally, the discharge summary for another resident who was transferred to an acute care hospital was incomplete, as it did not specify the reason for discharge. The ADON verified that the physician had not documented the basis for the transfer, leaving the discharge summary unfinished. These documentation failures were acknowledged by facility leadership and were not in accordance with the facility's policy on nursing documentation, which requires clear, accurate, and comprehensive records to communicate patient status and care provided.