Failure to Maintain Accurate and Complete Medical Records
Penalty
Summary
The facility failed to maintain accurate and complete medical records for multiple residents, as evidenced by discrepancies and omissions in documentation related to changes in condition, discharge events, and ongoing care. For one resident with a history of syncope, cerebral cysts, dementia, anxiety, and seizures, there were conflicting records regarding the date and circumstances of hospital discharge. The Change in Condition (CIC) form contained inaccurate dates and vital signs, and lacked documentation of the actual event that led to the resident's transfer. Interviews revealed that the nurse who completed the CIC form was not present during the incident and completed the form as a late entry based on secondhand information. The assigned nurse did not document the event, and there was confusion among staff regarding who was responsible for the documentation. The Director of Nursing (DON) and other staff acknowledged the inaccuracies and incompleteness of the medical record for this resident. Another resident, dependent on hemodialysis and with severe cognitive impairment, had physician orders specifying that blood pressure should not be taken on the arm with an arteriovenous (AV) fistula. Despite this, the medical record showed that nurses documented blood pressure readings from the restricted arm on numerous occasions over several months. Staff attributed these entries to data entry errors, but the documentation remained inaccurate. Additionally, weights for this resident were not entered into the medical record after a certain date, despite being available from other staff, resulting in incomplete records. The facility did not have a policy addressing the accuracy of medical record documentation. A third resident, admitted with fractures and atrial fibrillation, experienced a change in condition that was not accurately or completely documented in the medical record. Incident reports described symptoms such as shortness of breath, sweating, and functional decline, with staff interventions including vital sign checks, COVID-19 testing, and physician notifications. However, the electronic medical record lacked documentation of the COVID-19 test, some vital signs, physician notifications, and interventions such as supplemental oxygen administration. There were also inconsistencies between incident reports and the medical record regarding the timing and details of the resident's decline and the response by staff. The DON confirmed that there were gaps in the resident's medical record, failing to provide a full account of the change in condition and staff interventions.