Failure to Maintain Accurate and Complete Medical Records
Penalty
Summary
The facility failed to maintain accurate and complete medical records for two of three sampled residents. For one resident with diagnoses including type 2 diabetes, hypertension, hyperlipidemia, and chronic kidney disease, a Licensed Vocational Nurse (LVN) did not accurately document blood sugar checks and medication administration. The LVN recorded a blood sugar value and medication administration time that did not match the actual times and values, and admitted to documenting incorrect information in the Medication Administration Record (MAR). The LVN also administered medications earlier than ordered, per the resident's request, but failed to accurately reflect this in the MAR, resulting in discrepancies between the MAR and the progress notes. For another resident with a history of skull and facial bone fractures and severe cognitive impairment, the facility did not document the time or the physician's response after the physician was notified of a urine test result. The resident was dependent on staff for all activities of daily living and was always incontinent. The urinalysis result indicated that the physician was notified, but there was no documentation in the medical record regarding the time of notification or the physician's response. The Director of Nursing confirmed that the medical record was incomplete and that the responsible nurse should have documented the communication with the physician, including the date and time of notification and the physician's response. The facility's policy and procedure on "Completion and Correction" requires that medical records be completed and corrected in a standardized manner to ensure accuracy and quality, including documentation of each time a physician is notified regarding a resident's condition. In both cases, the facility failed to adhere to its own policy, resulting in incomplete and inaccurate medical records for the residents involved.