Inaccurate and Incomplete Medical Record Documentation for Two Residents
Penalty
Summary
The facility failed to maintain accurate and complete medical records for two residents, resulting in deficiencies related to documentation of falls, change in condition, and treatment administration. For one resident, after experiencing a fall, the licensed nurse completed a Change in Condition Evaluation but documented vital signs that were taken hours or days before the incident, rather than obtaining and recording new vital signs as required. Additionally, the same resident's fall risk assessment was completed inaccurately, omitting relevant medical history and medication use, and incorrectly indicating no risk for falls. The neurological assessment documentation was also inconsistent, with entries recorded after the resident had already been transferred to an acute care hospital. The facility's policies and procedures require that all incidents, accidents, and changes in condition be thoroughly documented, including the date, time, and assessment data. However, the review found that the required observations and assessments were either incomplete or inaccurately recorded. The Director of Nursing confirmed that the documentation did not meet facility standards and that the necessary information, such as vital signs and fall risk factors, was missing or incorrect in the resident's records. For another resident, the Treatment Administration Record (TAR) was found to be incomplete, with several days lacking documentation of a prescribed wound care treatment. The nurse responsible acknowledged that the treatment had been performed but was not documented at the time, as required by facility policy. This lapse in documentation resulted in an incomplete medical record for the resident.