Incomplete and Inaccurate Medical Record Documentation
Penalty
Summary
The facility failed to maintain complete and accurate medical records for three residents. For one resident, review of the Medication Administration Record (MAR) showed missing documentation of the amount of enteral nutrition administered on multiple dates, despite physician orders specifying the required feeding regimen. This omission was confirmed by the Assistant Director of Nursing/Infection Preventionist. Another resident's medical record lacked documentation regarding the reason and time of transfer to the hospital following an unwitnessed fall, and there was no post-fall nursing assessment recorded. Similarly, a third resident experienced a fall, but the medical record did not contain a status post-fall nursing assessment, even though a physician note referenced the incident. These documentation gaps were confirmed by facility nursing leadership during interviews.