Inaccurate Nursing Documentation for Resident Care
Penalty
Summary
The facility failed to ensure that nursing progress notes for one resident were accurate and properly documented. Specifically, a review of the resident's admission record showed the individual was admitted with diagnoses including acute respiratory failure, congestive heart failure, and dementia with severely impaired cognition. The resident was later sent to a general acute care hospital and subsequently expired. Upon review of the resident's daily nurse notes, it was found that entries made on a certain date were actually late entries for a previous date, but the nurse did not indicate that they were late entries or specify the actual date and time the events occurred. During interviews, the registered nurse acknowledged forgetting to document the entries as late and to include the correct timing. The Director of Nursing confirmed that documentation is required to be complete and accurate. The facility's policy also states that all services and changes in a resident's condition must be documented objectively, completely, and accurately. The failure to properly document late entries resulted in an inaccurate depiction of the care and services provided to the resident.