Inaccurate Post-Mortem Documentation in Medical Records
Penalty
Summary
The facility failed to maintain complete and accurate medical records in accordance with accepted professional standards for one resident. A review of the closed medical record for a resident who had died revealed that staff documented assessments and treatments as having been performed during the evening and night shifts on the date of the resident's death, despite the resident having already been pronounced deceased and released to the funeral home earlier that day. Documentation included administration of medications, completion of assessments for pain, oxygen monitoring, bleeding/bruising precautions, and other routine care tasks, all recorded after the resident was no longer present in the facility. Further review of the nurses' progress notes confirmed the resident experienced a change in condition, was assessed by EMTs, and was pronounced dead in the early afternoon. The Director of Nursing verified that the documentation by evening and night shift staff was inaccurate, as the resident was not in the facility at the time the care was recorded as provided. This discrepancy demonstrates that the medical records did not accurately reflect the resident's status or the care provided, constituting a failure to safeguard resident-identifiable information and maintain records according to professional standards.