Failure to Maintain Accurate and Complete Clinical Records
Penalty
Summary
The facility failed to maintain accurate and complete clinical records for three residents, as evidenced by documentation errors and omissions. For one resident receiving enteral feeding, the Medication Administration Record (MAR) did not consistently reflect the correct amounts of tube feeding formula and pre- and post-administration flushes as ordered by the physician. Documentation was inconsistent, with varying amounts recorded and no clear indication of whether flushes were administered as required. Another resident was noted in a physician's progress note to have a diagnosis of Post Traumatic Stress Disorder (PTSD), but a review of the clinical record, including psychiatric notes and care plans, revealed no supporting documentation for this diagnosis. The Social Service Director confirmed that there was no evidence of PTSD in the resident's history or assessments, and subsequent review by a Certified Registered Nurse Practitioner (CRNP) determined that the diagnosis was not warranted. A third resident experienced an unwitnessed fall resulting in a neck abrasion, after which a speech therapy screening was ordered and conducted. The initial speech therapy note recommended vocal rest and a follow-up assessment, but there was no timely documentation of the follow-up visit in the clinical record. The speech therapist later confirmed that the follow-up had occurred but was not documented until a late entry was made after the omission was discovered. The Nursing Home Administrator acknowledged that the clinical record should have been complete and accurate.