Failure to Maintain Complete and Accurate Clinical Records
Penalty
Summary
Facility staff failed to maintain complete and accurate clinical records for two residents. For one resident with an indwelling urinary catheter, staff did not document the catheter care provided each shift. Although the resident and a CNA confirmed that catheter care was performed regularly, there were no physician orders for catheter care and no documentation in the clinical record to reflect that this care was being provided. The CNA stated she was unaware of any place in the record to document this care. For another resident, staff did not document the initial observation of swelling and redness to the left knee. The resident, who had a history of coronary artery disease, dementia, atrial fibrillation, cerebrovascular accident, osteoarthritis, and previous knee replacement, was noted to have swelling and redness by a CNA, which was reported to the LPN. The LPN assessed the knee and notified the physician using a communication book, but did not document the assessment or findings in the medical record. The physician later evaluated the resident, ordered an x-ray, and the resident was sent to the ER after an acute fracture was identified. Facility policy requires that all actions taken in response to a resident's problem be documented in the medical record, as it serves as legal proof of care provided. In both cases, the lack of documentation failed to meet accepted professional standards for maintaining complete and accurate clinical records.