Inaccurate Medical Record Documentation and Failure to Follow Physician Orders
Penalty
Summary
Facility staff failed to maintain complete and accurate medical records for multiple residents, as evidenced by documentation of assessments and medication administration for residents who were not present in the facility. For one resident, staff documented a Change in Condition Assessment, neurological checks, pain assessment, and skilled nursing charting after the resident had been transferred to the emergency room and did not return. Additionally, medication administration was recorded for this resident on the day following their discharge from the facility. Another resident's records showed that staff documented the administration of multiple medications and treatments, including wound care and tube feeding, on a date after the resident had been transferred to the hospital and was no longer in the facility. The Director of Nursing confirmed that these entries were inaccurate and that the resident was not present at the time the care was documented. A third resident, who was on hospice care, had physician orders to have their heels floated while in bed. Despite this, repeated observations found the resident's heels resting directly on the mattress, with no elevation as ordered. Nursing staff had signed off in the Treatment Administration Record that the heels were elevated during these periods, even though direct observation by surveyors and the DON confirmed otherwise.