Incomplete and Inaccurate Medical Record Documentation
Penalty
Summary
The facility failed to ensure that medical records for several residents were accurate and complete, as required by professional standards. For one resident with end stage renal disease and multiple comorbidities, there was no physician order for dialysis in the electronic record, despite the resident receiving dialysis at the facility. Additionally, documentation was missing for medication administration and treatments during specific shifts, and staff interviews confirmed lapses in documentation and the absence of required orders. Another resident, admitted with multiple chronic conditions and using a noninvasive ventilator, had incomplete documentation regarding a scheduled CT scan. While respiratory therapy and pharmacy reviews were documented, there was no record of the CT scan results or when it was completed, which was confirmed by the DON. For a third resident, the nursing admission assessment was left blank in the electronic health record, with the DON attributing this to a possible system glitch, but no assessment information was present in the record. Additionally, the review of another resident's electronic medical record revealed that physician notes for a different resident were incorrectly filed in their record. The facility's policy requires that medical records be complete, accurately documented, and systematically organized, but these findings demonstrate that the facility did not meet these standards for multiple residents.