Deficiencies in Clinical Record Accuracy and Documentation
Penalty
Summary
Surveyors identified multiple deficiencies related to the maintenance of accurate and complete clinical records for several residents. For one resident, there was conflicting documentation regarding the presence of an Advance Directive. The admission record and Advance Healthcare Directive Acknowledgment indicated the resident did not have an Advance Directive, while the Psycho-Social Assessment stated otherwise. This inconsistency was confirmed by the Social Service Director, who acknowledged the documentation was inaccurate and could cause confusion regarding the resident's care preferences. Another deficiency involved the administration and documentation of medications. An LVN administered several medications to a resident earlier than the scheduled time and failed to document the actual time of administration in the Medication Administration Record (MAR). Instead, the LVN later recorded the medications as being given at the scheduled time, which was not accurate. Interviews with nursing staff and review of facility policies confirmed that medications should be administered and documented at the correct times, and any deviations should be clearly recorded. The inaccurate documentation in the MAR had the potential to mislead staff about the resident's medication administration throughout the day. Additional findings included incomplete informed consent documentation for psychotropic medications for two residents. In one case, informed consent forms for medications were not signed and dated by the physician, and in another, the physician's signature was undated and the verification method by the nurse was not completed. Facility policy required that informed consent forms be fully completed, including signatures, dates, and verification details. The lack of complete documentation for informed consent and medication administration was confirmed by nursing leadership and was not in accordance with the facility's own policies and accepted professional standards.