Failure to Maintain Accurate and Complete Medical Records
Penalty
Summary
The facility failed to maintain accurate and complete medical records for three residents, resulting in multiple documentation deficiencies. For one resident, the facility did not document the names or quantities of 12 medications provided to a family member upon request, including two controlled substances. The medications were given without a physician's order, and the nurse involved could not recall the specific medications or amounts dispensed. Facility policy required clear and complete documentation of all medications sent with a resident, but this was not followed. Another resident's medical record contained inaccurate documentation regarding behavioral incidents. Nursing staff repeatedly documented that the resident was throwing himself on the floor over a period of several days, despite no such behavior being observed or reported by other staff. Interviews revealed that nurses had copied and pasted previous documentation rather than recording actual observations, leading to a false record of the resident's behavior. A third resident experienced a fall, and although a nurse reported taking the resident's vital signs, this assessment was not documented in the medical record. The facility's policy required that all assessments and observations following a change in condition, such as a fall, be documented in the resident's record. The lack of documentation meant that there was no record of the resident's vital signs at the time of the incident.