Incomplete and Inaccurate Medical Record Documentation for Two Residents
Penalty
Summary
The facility failed to ensure complete and accurate medical record documentation for two residents. For one resident with dementia and other psychiatric diagnoses, there was no nursing progress note documenting an elopement incident in which the resident left the building undetected and was returned by a community member. The LPN assigned to the resident during the incident reported being instructed not to document the event, and the only note present was written later by the DON, who had not witnessed the incident. The documentation did not reflect the actual sequence of events or the resident's condition during the elopement, and there was inconsistency among staff regarding instructions for documentation. For another resident with osteomyelitis and a history of stroke and pressure ulcers, there was a discrepancy between the physician's order for antibiotic administration and the documentation in the medical record. The order specified the antibiotic was to be given until a certain date, but the medication administration record showed the last dose was given a day earlier, while nursing notes incorrectly indicated the antibiotic was still being administered after it had been discontinued. There were no additional physician orders to continue the antibiotic, and the DON was unable to provide clarification for the documentation inconsistencies.