Incomplete and Inaccurate Clinical Record Documentation
Penalty
Summary
The facility failed to maintain complete and accurate clinical records for a resident who experienced an incident resulting in hospital transfer for evaluation of increased behaviors. The clinical record did not contain documentation of notification or attempted notification of the resident's representative regarding the hospital transfer. Additionally, there was no documentation from the charge nurse in the nurses/progress notes about the resident's behaviors, as was required by the Treatment Administration Record (TAR). Although the TAR indicated that behaviors were monitored, there was no corresponding narrative documentation in the clinical record. Further review revealed that the clinical record lacked information indicating when the resident returned to the facility after the hospital transfer. Interviews with staff confirmed that the LPN had called and left a message for the resident's representative but did not document this action in the clinical record. The RN acknowledged documenting on the TAR but failed to update the clinical record with details of the behaviors or the resident's return from the hospital. These omissions resulted in incomplete and inaccurate clinical records for the resident involved in the incident.