Incomplete and Inaccurate Clinical Record Documentation for Two Residents
Penalty
Summary
Facility staff failed to ensure complete and accurate clinical records for two of ten sampled residents. For one resident, staff incorrectly documented the location of a foot wound, recording it as being on the left foot in the skin assessment, treatment administration record, and wound assessment report, when the wound was actually on the right foot. Medical provider notes and orders referenced both feet inconsistently, but the wound nurse and DON later confirmed the documentation error. The facility was unable to provide a policy for accurate documentation when requested by surveyors. For another resident, staff failed to document the administration of scheduled oxycodone on the medication administration record (MAR) for multiple dates and times, despite the medication being administered and recorded on the controlled drug administration record (NARC log). The resident had multiple diagnoses, including chronic pain and moderate cognitive impairment. The facility's policy required documentation of medication administration on the MAR, but this was not followed for the identified dates.