Failure to Maintain Accurate and Complete Medical Records
Penalty
Summary
The facility failed to ensure that residents' medical records were accurate and complete, as required by both facility policy and federal and state regulations. For one resident with paraplegia and multiple complex wounds, there were numerous instances where the Treatment Administration Record (TAR) lacked documentation that wound care treatments were provided as ordered. Specific dates and wound sites were identified where no evidence of treatment administration was recorded, despite staff interviews indicating that wound care was performed but not always documented. The Director of Nursing and the Administrator both confirmed that staff are expected to document treatments on the TAR when completed. For another resident with multiple chronic conditions, including diabetes, heart failure, and chronic obstructive pulmonary disease, the Medication Administration Record (MAR) showed multiple missing entries for the administration of prescribed medications such as Percocet, DuoNeb, Humalog, and Lantus. Staff interviews revealed that nurses and aides experienced frequent computer and internet issues, which sometimes prevented them from completing or saving documentation in the electronic medical record system. Some staff reported being unable to sign out medications on the MAR due to technical problems, and these issues were known to at least one member of management. The facility's own policy requires that all treatments and medications, including refusals, be accurately documented in the resident's medical record. Despite this, the records for both residents were incomplete, with missing documentation for both wound care and medication administration. The lack of documentation was confirmed through record review and staff interviews, and the facility leadership acknowledged the expectation for complete documentation.