Inaccurate Documentation of Care for Absent Residents
Penalty
Summary
Licensed nursing staff failed to meet professional standards of practice by documenting assessments, medication administration, and treatments for residents who were not present in the facility. For one resident admitted for rehabilitation following hospitalization, staff documented a change in condition assessment, neurological checks, pain assessment, and skilled charting after the resident had been transferred to the emergency room and did not return. Additionally, medication administration was recorded for this resident after discharge, including specific medications and times, despite the resident's absence from the facility. The Director of Nursing confirmed these inaccuracies in documentation. Similarly, for another resident who had been transferred to the hospital and did not return, staff documented the administration of multiple medications and completion of various treatments, such as wound care and tube feeding, on a date after the resident had left the facility. The Director of Nursing also confirmed that these entries were inaccurate. These actions constitute violations of professional documentation standards, as records did not accurately reflect the residents' status or care provided.