Inaccurate Documentation in Resident Medical Records and CPAP Care
Penalty
Summary
The facility failed to ensure that resident records contained accurate documentation for two residents. For one resident with multiple diagnoses including dysphagia and vitamin D deficiency, the medical record showed inconsistent and inaccurate weight entries over several months. A weight recorded on 5/13/25 was later crossed out as inaccurate, but this incorrect value was still used in both the Quarterly Nutritional Assessment and the Quarterly MDS assessment. The Director of Nursing confirmed that these assessments reflected the inaccurate weight. For another resident with obstructive sleep apnea, the care plan and physician orders required daily cleaning of the CPAP mask and weekly replacement of tubing. The Medication Administration Record (MAR) indicated that staff signed off on completing these tasks, but review showed that the order to assist with CPAP placement was not signed off as completed on multiple dates. An LPN stated she did not clean the CPAP machine, despite her credentials indicating otherwise, and the DON reported that the CPAP machine had not worked for two weeks, with no explanation for the inaccurate MAR documentation.