Incomplete and Inaccurate Medical Record Documentation for Infection Control and Restorative Nursing Services
Penalty
Summary
The facility failed to maintain complete and accurate medical records in accordance with accepted professional standards for multiple residents. For several residents with cognitive impairments or lacking decision-making capacity, COVID-19 screening forms were incomplete, specifically missing required temperature documentation at the time of screening. Additionally, vaccination informed consent forms for COVID-19, influenza, and pneumococcal vaccines were not fully completed, lacking essential information such as the name and relationship of the resident’s representative, and in some cases, the resident’s name. These omissions were confirmed by both nursing staff and facility leadership, who acknowledged that incomplete consent forms constitute incomplete medical records. For residents receiving Restorative Nursing Aide (RNA) services, the facility did not accurately document the actual care provided. In one case, a resident’s RNA Weekly Progress notes did not reflect the resident’s true ability to ambulate, with discrepancies between the recorded ambulation distances and what was observed or reported by staff. The RNA daily treatment records also inaccurately indicated that ambulation was provided on certain days when, in fact, it was not performed due to the resident requiring assistance from two staff members, which was not available. Staff interviews confirmed that the documentation did not match the care delivered, and that the electronic documentation system was not used correctly to indicate when services were missed or not performed. Additional documentation failures included not recording missed RNA treatments for several residents and not documenting a resident’s inability to participate in sit-to-stand transfers. Facility policies required accurate and timely documentation of restorative nursing services and complete informed consent forms, but these standards were not met. The Director of Nursing and Assistant Director of Nursing confirmed that these documentation lapses resulted in incomplete and inaccurate medical records, which could lead to confusion regarding the care and services provided to residents.