Failure to Maintain Accurate Medical Record Documentation
Penalty
Summary
Facility staff failed to maintain a complete and accurate medical record for one resident. The clinical record for this resident documented a discharge date, but a progress note was entered with a date after the resident had already expired and was no longer in the facility. The note described an advanced care planning discussion with the resident's responsible party and the DON, referencing the resident's ongoing decline, multiple hospitalizations, and poor prognosis. However, the nurse practitioner who authored the note confirmed in an interview that the entry was made after the resident's death and should have been documented as a late entry, which it was not. The administrator reviewed the progress note and confirmed that the resident was not present in the facility on the date indicated in the documentation, acknowledging the inaccuracy of the medical record. Facility policy requires that documentation be completed at the time of service or during the shift in which care occurred, and that any late entries be clearly indicated as such. The failure to properly document the timing and nature of the entry resulted in an incomplete and inaccurate medical record for the resident.