Failure to Maintain Accurate and Complete Medical Records
Penalty
Summary
Facility staff failed to maintain accurate and complete medical records for two residents. For one resident, a review of the closed medical record revealed that the Medical Orders for Life-Sustaining Treatment (MOLST) form was incomplete, as the front page did not indicate the resident's wishes regarding life-sustaining care. The certified registered nurse practitioner (CRNP) responsible for completing the form acknowledged during an interview that the first page had not been filled out after discussing care preferences with the resident. For another resident, progress notes written by the staff developer included late entries documenting that the resident had refused showers, received education, and that notifications were made to the resident representative and physician. However, a review of the geriatric nursing assistant (GNA) documentation showed no record of a shower refusal, but rather that a bed bath was given. The staff developer later clarified that while the refusals were based on shower sheets, the education and notifications did not occur on the dates documented in the progress notes, resulting in inaccurate recordkeeping. The director of nursing agreed that the progress notes did not accurately reflect the events that occurred.