Incomplete and Inaccurate Resident Record Documentation
Penalty
Summary
The facility failed to ensure that resident records were complete and accurate for two residents. For one resident with morbid obesity and type II diabetes mellitus, there was a physician's order for weekly skin assessments. Despite this, recent skin assessments did not document a visible bruise on the resident's left forearm, which was observed by the surveyor. Staff interviews confirmed that the bruise should have been noted in the weekly skin assessment, but it was omitted from the documentation. For another resident with a history of stroke and residual hemiparesis, the nurse inaccurately documented the administration of a scheduled dose of miralax on the Medication Administration Record (MAR), even though the resident had declined the medication and it was not given. The nurse acknowledged the error, stating that the medication should have been documented as not administered or refused. The Director of Nursing confirmed that the documentation was inaccurate.