Inaccurate and Incomplete Medical Record Documentation
Penalty
Summary
The facility failed to ensure accurate and complete documentation in the electronic medical records (EMR) for several residents, as evidenced by discrepancies between documented care and actual observations, as well as missing or incorrect entries. For one resident, the care plan required wheelchair brake extenders with highlighted tape due to recent falls, yet multiple observations revealed the device was not present, despite staff documenting that all safety devices were in place. Interviews with CNAs revealed a lack of knowledge regarding the specific safety interventions required, and documentation was completed without verifying the actual presence of the devices. Another resident's administration history indicated receipt of a specific enteral feeding formula, but direct observation showed a different formula was being administered, and the feeding bag was labeled with an incorrect date. The LPN responsible acknowledged the documentation was inaccurate. Additionally, a resident's oxygen tubing was documented as being changed weekly, but observations showed the tubing had not been changed according to the documented schedule, and staff were unable to confirm when it was last changed. Further deficiencies included a mismatch between a resident's documented code status in the electronic record (Full Code) and the paper record (DNR), with staff interviews confirming the electronic record was incorrect. For another resident, there was no documentation to show whether scheduled baths or showers were provided or refused on multiple dates, and the DON confirmed that such documentation should have been completed. In each case, the administrator and DON were unable to provide explanations or evidence to dispute the findings.