Incomplete and Inaccurate Medical Record Documentation
Penalty
Summary
The facility failed to maintain complete and accurate medical records for one resident, as evidenced by missing documentation on the Treatment Administration Record (TAR) for multiple physician-ordered treatments and interventions. Specifically, there were no entries from licensed nurses for several ordered tasks, including application of fluocinonide cream, transferring the resident to a wheelchair, floating the heels, oral hygiene after meals, use of a foot brace, monitoring an ingrown toenail, and use of a PRAFO device. When questioned, a licensed nurse confirmed that the documentation was missing and could not verify whether the tasks had been completed as ordered. Additionally, there was inaccurate documentation regarding the provision of oral hygiene. The resident reported not receiving oral care, and a CNA confirmed during an interview that oral care supplies had not been set up and that she had not provided oral care, despite having documented that it was done. The DON verified these findings, indicating that the resident's clinical record did not provide a concise and accurate account of the care and treatments provided, as required by facility policy.