Inaccurate Medical Record Documentation and Communication Failure
Penalty
Summary
The facility failed to maintain accurate and professionally documented medical records for one resident. The resident, who had a history of traumatic cerebral hemorrhage and severe cognitive impairment (BIMS score of 4), was admitted and later readmitted to the facility. The clinical record showed discrepancies in documentation, including a physician order for foley catheter removal and a treatment administration record indicating the catheter was removed. However, subsequent urology nurse practitioner (NP) consult notes repeatedly documented male genitalia assessments for a female resident and indicated the presence of a foley catheter after it had been removed. The NP confirmed during interviews that these entries were incorrect and that the resident was female, acknowledging that the male-specific information should not have been included. Additionally, the NP stated that he had not communicated with the resident's family or representative regarding significant findings, such as a right kidney mass identified on ultrasound, despite the resident's severe cognitive impairment. The NP admitted that he typically only contacts family if the resident is alert and did not reach out to the family or representative in this case. These actions and omissions resulted in medical records that were not accurately documented in accordance with accepted professional standards and practices.