Failure to Maintain Accurate and Complete Medical Records
Penalty
Summary
Nursing staff failed to maintain accurate and complete medical records for two residents. For one resident with quadriplegia and multiple contractures, there was a physician's order for the application of left elbow, left hand, and bilateral knee splints for three to four hours daily, as well as passive range of motion (PROM) exercises. Observations revealed that the left hand splint was not applied for at least two weeks, and staff interviews confirmed the splint was missing and not used. Despite this, there was no documentation in the resident's medical record indicating the left hand splint was not applied, nor any record of the missing splint or communication to the physician or family. The care plan and physician's orders clearly required this intervention, but the lack of documentation resulted in incomplete and inaccurate records regarding the resident's care. For another resident, the facility failed to ensure a diagnosis of anxiety was documented prior to the initiation of a routine anti-anxiety medication, clonazepam. The resident's admission record and Minimum Data Set (MDS) did not list anxiety as a diagnosis, even though the resident was receiving clonazepam for anxiety manifested by agitation and restlessness. The Assistant Director of Nursing confirmed that the medication was being administered without the required supporting diagnosis in the medical record, which is necessary to validate the use of psychotropic medication. Facility policy required documentation of relevant findings in the clinical record and comprehensive, accurate assessments that include disease diagnoses and health conditions. In both cases, the failure to document either the omission of a prescribed intervention or the diagnosis supporting medication administration resulted in medical records that were not accurate or complete, as required by facility policy and professional standards.