Incomplete and Inaccurate Medical Record Documentation for New Admission
Penalty
Summary
The facility failed to ensure that medical records were complete and accurate for a resident who was admitted following a coronary artery bypass grafting (CABG). Upon admission, nursing notes did not document an assessment of the resident's skin or indicate the presence of any skin issues or bruising. Although the admission observation stated there were no alterations in the resident's skin, a subsequent skin assessment several days later noted incisions and bruising, but did not specify the location of the bruising. There was no documentation in the nursing notes between admission and the later assessment that referenced any bruising. Interviews with nursing staff revealed that the resident was admitted with closed incisions and bruising, which had been reported by the hospital prior to admission. However, the facility's admission assessments, skin assessments, and notes did not document the presence of incisions or bruising at the time of admission. The Director of Nursing confirmed the lack of documentation and was in the process of obtaining provider progress notes to verify the resident's condition upon admission. The facility's job description for medical records staff includes responsibilities for tracking and uploading physician notes and auditing records for discrepancies, which was not adequately performed in this case.