Failure to Ensure Timely and Accurate Medical Record Documentation
Penalty
Summary
The facility failed to ensure timely and accurate documentation of medical records for several residents, as evidenced by interviews and record reviews. Multiple instances were identified where medications were administered but not documented in the Medication Administration Record (MAR) at the time of administration. For one resident, medications scheduled for 9 PM were consistently signed off as complete well after 11 PM, with notes indicating that charting was done late but medications were administered on time. The Director of Nursing confirmed that medications are expected to be administered and documented within a specific timeframe, and acknowledged that the documentation was not completed as required. Further review of other residents' MARs revealed similar patterns of late documentation. For another resident, both afternoon and evening medications, including insulin and other critical medications, were signed off several hours after the scheduled administration times, again with notes stating that charting was late. Another resident's MAR showed delayed documentation for antibiotics, with charting occurring hours after the scheduled dose. These findings were corroborated by the facility's own Medication Management Program Policy, which requires immediate documentation after medication administration. Additionally, a review of medical records for a resident who was admitted and then discharged to the hospital revealed a lack of appropriate nursing documentation. Only one progress note was found for the period in question, and a relevant nursing note was incorrectly filed under the record of the resident's spouse rather than the correct resident. Both the Nursing Home Administrator and the Director of Nursing confirmed the absence of proper documentation and acknowledged the error in record-keeping.