Failure to Maintain Accurate and Complete Medical Records
Penalty
Summary
The facility failed to maintain complete and accurate medical records for one resident, resulting in multiple inconsistencies and errors. The resident's code status was documented inconsistently across various records: the admission observations and face sheet listed the resident as Full Code, while the POLST form, signed by the resident, indicated Do Not Attempt Resuscitation (DNAR). The POLST form was not signed by a provider until 13 days after the resident's admission, and after the resident had already been transferred to the hospital. The Physician Order Sheet (POS) continued to list the resident as Full Code, which conflicted with the POLST. The Director of Nursing and Resident Service Director confirmed these discrepancies and acknowledged that the POLST and POS were incongruent and incomplete at the time of the resident's transfer to the hospital. Additional documentation errors were identified in the resident's progress notes. The Social Service Director documented that the resident was discharged home from the hospital, which was inaccurate, as the resident had expired in the hospital. The Social Service Director admitted to not verifying this information with the family before documenting it. Furthermore, the Medication Administration Record (MAR) indicated that a nurse had administered Fosinopril to the resident before the medication had been delivered to the facility, which was confirmed by pharmacy delivery records and the Director of Nursing. The nurse acknowledged that the medication could not have been administered as documented. These findings demonstrate failures in maintaining accurate and complete medical records for the resident.