Failure to Maintain Accurate and Complete Clinical Records
Penalty
Summary
The facility failed to maintain accurate and complete clinical records for multiple residents, as required by professional standards and facility policy. In one instance, a registered nurse did not document the physician's reply on the change of condition/SBAR form after a resident experienced an unwitnessed fall. Although the physician was notified and gave an order to hold the resident's anticoagulant for three days, this information was not recorded on the form. Both the nurse and the Director of Nursing confirmed that the physician's response should have been documented, regardless of whether new orders were given, to ensure all staff were aware of the interventions provided. In another case, a resident with a tracheostomy and dependence on a ventilator had missing documentation in the respiratory therapy electronic Medication Administration Record (eMAR) for two scheduled treatments. Both the registered nurse and the respiratory therapist acknowledged that the required documentation was not completed after the treatments, as mandated by physician orders and facility policy. The Director of Nursing also confirmed that all documentation should be completed prior to staff leaving the facility to ensure accuracy and continuity of care. Additionally, a certified nursing assistant inaccurately documented the amount of food a resident consumed during lunch, recording that the resident ate 50% of the meal without verifying the tray, when in fact the food was untouched. The same resident's blood pressure was not measured as ordered every six hours; instead, a licensed vocational nurse used a previous reading for a later time slot. Furthermore, the nurse documented zero crying spells for the resident, despite reports and observations that the resident had been crying throughout the day. These actions resulted in incomplete and inaccurate information in the residents' medical records.