Failure to Maintain Accurate and Complete Medical Records
Penalty
Summary
Facility staff failed to maintain complete and accurate medical records in accordance with accepted professional standards for two residents. In one instance, a review of a closed medical record revealed that a physician certification of incapacity for one resident was incorrectly filed in another resident's record. The certification, which documented incapacity due to dementia, was signed and dated by the physician, but a second certificate in the same record pertained to a different resident entirely. The facility administrator was unaware of this error until it was identified by the surveyor. In another case, a complaint alleged improper administration of pain medication to a resident who had been admitted following lower extremity surgery. Physician orders directed nursing staff to administer pain medication as needed. Medication administration records showed three documented doses of Dilaudid on a specific date, but a printout from the interim medication dispensing machine indicated an additional dose was administered that was not documented in the resident's medical record. The nurse involved confirmed that the medication was given but admitted to forgetting to document the administration.