Inaccurate Medical Records and Documentation Errors
Penalty
Summary
The facility failed to maintain accurate and complete medical records for three residents, resulting in discrepancies in physician orders, medication administration records, and therapy documentation. For one resident, the physician's order for tube feeding did not specify a start time, leading to inconsistent administration of enteral nutrition. Observations showed the resident's feeding pump was turned off at times, and staff interviews confirmed that all enteral feedings were typically started at a set time, despite the lack of a specified start time in the order. Both nursing staff and the DON verified that the order was incomplete and should have included this critical detail. Another resident's medical record contained inaccurate RNA documentation. The active and passive range of motion interventions, as well as the application of a hand splint, were documented with a code indicating 'Not Applicable' instead of the correct code for resident refusal. The RNA staff member explained that this miscoding was due to CNA documentation practices, which could not be overridden by RNA staff, and acknowledged this was an ongoing issue. This resulted in the resident's therapy interventions not being accurately reflected in the medical record. A third resident's medication administration record (MAR) was found to be inaccurate regarding the administration of oxycodone. The controlled drug record showed the removal of a 15 mg dose at specific times, but the MAR indicated that a 10 mg dose was administered at one of those times, and the 15 mg dose was documented as given before it was actually removed from storage. The DON confirmed that the process required documentation on both the controlled drug record and the MAR, and acknowledged the discrepancies found in the records.