Incomplete and Inaccurate Medical Record Documentation for Two Residents
Penalty
Summary
The facility failed to ensure complete and accurate documentation for two residents. For one resident with chronic obstructive pulmonary disorder, dementia, and morbid obesity, a dirty nebulizer machine was observed on the floor, with the face mask not stored in a bag and dated over a month prior. Review of the Medication Administration Record (MAR) revealed multiple instances where required documentation for administration of ipratropium-albuterol nebulizer solution was incomplete or missing, including omissions of pulse, respirations, breath sounds, and minutes of therapy before and after administration across several dates. For another resident with neurogenic bladder, severe morbid obesity, and diabetes, the physician's order required recording urine output from a urinary catheter every shift. The Treatment Administration Record (TAR) showed missing documentation of urinary output for several shifts during the period the order was active. During an interview, the Director of Nursing confirmed that all documentation should have been completed, and there was no facility policy on documentation.