Incomplete and Inaccurate Medical Record Documentation for Two Residents
Penalty
Summary
The facility failed to maintain complete and accurate medical records in accordance with accepted professional standards for two residents. For one resident, the nursing staff documented the administration of wound care treatment to the left knee prior to actually providing the treatment. The Treatment Nurse stated that Betadine was applied and the dressing was changed at the end of the day, but the Treatment Administration Record (TAR) showed documentation of the treatment earlier in the day. The nurse admitted to documenting the treatment as completed before actually performing it, which was not consistent with professional standards and could result in missed treatments. The Director of Nursing confirmed that documentation should occur after the treatment is provided and acknowledged that the TAR was not accurate, which could have led to missed care. For another resident, the facility did not develop a complete Change in Condition (COC) Evaluation form after the resident experienced a fall. The COC evaluation form was marked incomplete and could not be reviewed by the surveyor. The Assistant Director of Nursing confirmed that the charge nurse did not sign and complete the form, and stated that licensed staff are required to develop a complete and accurate evaluation after a resident's change of condition. The incomplete documentation meant that the resident's medical record was not valid and could result in the resident not receiving appropriate care due to inaccurate information. Both deficiencies were identified through interviews, record reviews, and observations. The facility's policies required that all services provided be documented in the resident's medical record in accordance with state law and facility policy, and that documentation be factual and completed at the time of service or no later than the end of the shift. The failures in documentation for both residents were not in accordance with these policies and accepted professional standards.