Inaccurate Documentation of Resident Care in Medical Records
Penalty
Summary
The facility failed to ensure accurate documentation of medical records for two of three sampled residents. For one resident, a physician's order required suprapubic catheter care to be performed every shift. However, review of the electronic Medication Administration Record (eMAR) showed that an LPN documented the catheter care as completed, but later admitted in an interview that she did not perform the care during her shift as ordered. For another resident, physician's orders required both suprapubic catheter care every shift and the use of a pressure relieving cushion on the resident's wheelchair to prevent skin breakdown. The eMAR reflected that catheter care and the presence of the cushion were documented as completed by multiple LPNs on several shifts. However, observation revealed the resident was sitting in the wheelchair without the cushion, and the resident reported not having had a cushion in months. One LPN admitted to documenting catheter care and the presence of the cushion without verifying or performing these tasks. The Director of Nursing confirmed the documentation was inaccurate, and the Administrator did not dispute the findings.