Failure to Maintain Accurate and Complete Medical Records
Penalty
Summary
The facility failed to ensure that resident records were accurate, complete, and maintained in accordance with accepted professional standards and practices. For one resident with dementia, mood disorder, chronic pain, and kidney disease, discrepancies were found between physician and nurse practitioner notes and the actual medication orders and administration records. Specifically, the physician's note referenced a PRN order for Lorazepam, but the resident was receiving it on a scheduled basis, and the medication administration record did not reflect a PRN order. Additionally, the nurse practitioner's notes indicated that certain lab tests were to be performed, but there was no documentation that these labs were ordered or completed as stated. Another nurse practitioner's note referenced a medication (Lidocaine) that was not actually ordered or administered, and the practitioner acknowledged this was likely a documentation error due to not updating the note template. For a resident with a tracheostomy, documentation in the Treatment Administration Record (TAR) inaccurately reflected that a registered nurse had performed tracheostomy care, when in fact the care was provided by a respiratory therapist. The nurse confirmed that she documented the care as completed, even though she had not performed it, resulting in the TAR not accurately reflecting the resident's care experience. The Director of Nursing and Regional Director of Nursing also acknowledged that the documentation did not match the actual care provided. In another case, a resident who had been readmitted from the hospital did not have care planning meeting notes documented in the electronic medical record. When the surveyor was unable to locate the documentation, the Social Services Director provided a handwritten note as evidence of a care planning meeting, but confirmed that this note was not considered part of the official medical record. The Director of Nursing confirmed that care planning meeting notes are expected to be documented in the resident's medical record, but this was not done in this instance.