Inaccurate Medical Record Documentation for Multiple Residents
Penalty
Summary
The facility failed to ensure that information documented in the medical records was accurate for three residents. For one resident with paraplegia, a stage III pressure ulcer, and other complex diagnoses, the discharge documentation inaccurately stated that the resident was discharged to another nursing facility, when in fact the resident was observed leaving the facility independently in a wheelchair and was not admitted to another facility. The discharge notice also included allegations that the resident had threatened others, but the actual discharge location was not as documented. Another resident with multiple medical and psychiatric diagnoses, including a recent shoulder fracture from a fall, had an X-ray confirming a fracture dislocation. The LPN documented that the X-ray results were reviewed and that there were no new orders, but during interviews, it was revealed that the physician was not notified of the results as required. The medical director confirmed he was unaware of the X-ray findings until two days later and would have sent the resident to the hospital had he been informed. A third resident with psychiatric and substance use diagnoses had a late entry progress note indicating that the provider was notified about discontinuation of one-to-one supervision. However, the LPN later admitted that this documentation was false and that no provider was actually notified. Facility policy required that documentation in the medical record be objective, complete, and accurate, which was not followed in these cases.