Failure to Maintain Accurate and Complete Medical Records
Penalty
Summary
The facility failed to maintain medical records in accordance with accepted professional standards by not ensuring complete and accurate documentation and by misfiling documents. For one resident with a history of acute respiratory failure, sleep apnea, and thrombotic pulmonary embolism, there was a physician order for continuous oxygen therapy. However, for 21 out of 28 days, the vital sign documentation indicated that oxygen saturation readings were taken while the resident was on room air, despite the order for continuous oxygen. The Director of Nursing confirmed that this documentation was erroneous after speaking with the nursing staff. In another case, a hospice respite resident's medical record did not contain documentation of a hospice staff visit, during which medications were administered for comfort following a fall, even though the hospice provider confirmed the visit and interventions took place. Additionally, during a review of a resident's paper medical record, documentation belonging to a different resident was found misfiled in the chart. The misfiled documents included an appointment slip, a transportation form, and a consultation note. The error was recognized by a registered nurse when returning the documents to the chart, and the issue was reported to the Regional Director of Nursing, who acknowledged that the documents had been filed in the wrong chart.