Incomplete and Inaccurate Medical Record Documentation
Penalty
Summary
The facility failed to maintain complete, accurate, and accessible medical records for multiple residents, as required by accepted professional standards and state law. Documentation for several residents included inconsistencies such as care plans and assessments with future-dated entries, late documentation of interdisciplinary care conferences, and missing signatures. Staff interviews revealed that some documentation was completed on paper and later transcribed into the electronic record due to technical issues, resulting in delayed and potentially unreliable entries. There was also an absence of an auditing process to ensure the accuracy and completeness of medical records, as acknowledged by the Administrator and Director of Nursing Services. Medication Administration Records (MARs) for one resident showed missing documentation of required weekly weights on several dates. Additionally, the immunization records for several residents lacked documentation of the lot number and expiration date for tuberculosis (TB) testing solutions, which staff confirmed should have been recorded in the clinical record. The Director of Nursing Services stated that if this information was not documented under the immunization tab, it would not be found elsewhere in the record. The facility also permitted the use of a stamped signature by an LPN/RCM to indicate that pharmacy recommendations and physician orders had been noted and implemented. The Administrator stated that stamped signatures were not allowed and were not legal in the state, and was unaware that this practice was occurring. These documentation failures were observed across one of two resident units and affected at least six residents, placing them at risk for records that did not accurately reflect their care.