Incomplete and Inaccurate Medical Record Documentation
Penalty
Summary
The facility failed to ensure that medical records for two residents were complete and accurate, as evidenced by discrepancies in physician orders and medication documentation. For one resident, there were conflicting orders for a pressure-relieving mattress and an air mattress, with both orders documented as completed on the Treatment Administration Record (TAR) despite only one type of mattress being present. Staff interviews revealed uncertainty about which order should be followed, and it was later clarified that the air mattress order should have been discontinued after a decision by the family and physician. Additionally, a physician order for the resident to be out of bed on specific days did not transfer to the TAR, resulting in the order not being visible or actionable for nursing staff. For another resident, a nursing progress note indicated that pain medication was administered at a specific time, but there was no corresponding documentation in the Medication Administration Record (MAR) or controlled drug records to confirm that any medication was given at that time. Staff interviews confirmed that medications should be documented in the MAR immediately after administration, and there was no evidence to support that the medication was provided as noted in the progress note. These findings demonstrate lapses in maintaining accurate and complete medical records in accordance with professional standards.