Failure to Maintain Accurate Medical Records and Documentation
Penalty
Summary
The facility failed to ensure the accuracy of medical records for two residents. For one resident with multiple diagnoses including stroke, parkinsonism, and cognitive impairment, the Medication Administration Record (MAR) documented that various medications, enteral feedings, and g-tube flushes were administered as ordered. However, interviews with the Administrator and DON confirmed that no medications or treatments were actually provided during a specified time period, and the MAR had been falsified by a nurse. The facility's investigation into a neglect allegation revealed that the resident's physician-ordered treatments were not carried out as documented. For another resident with diagnoses including diabetes, COPD, dementia, and hypertension, the MAR indicated that weekly skin assessments were completed on several dates. However, review of the medical record and interviews with the DON and Administrator confirmed that no skin assessments had been performed since a prior date, despite documentation to the contrary. These findings demonstrate that the facility did not maintain accurate medical records in accordance with accepted professional standards.