Failure to Maintain Accurate and Complete Medical Records for Two Residents
Penalty
Summary
The facility failed to maintain accurate and complete medical records for two residents, resulting in deficiencies in documentation and communication among healthcare providers. For one resident with a history of ESBL resistance, Klebsiella infection, and Alzheimer's disease, the IV therapy medication record was not initialed by the night shift nurse for multiple consecutive days, indicating that required IV site checks were not documented. Additionally, the record contained inaccurate information, as a nurse documented an IV flush and site check after the resident's IV access had already been removed. The IV therapy medication record was also missing essential information such as the physician's name, allergies, and diagnoses, contrary to facility policy. Interviews with nursing staff confirmed that documentation was incomplete and, in some cases, inaccurate, with one nurse unable to explain why her initials appeared for a procedure that was not performed. Another resident, who was dependent on a gastrostomy tube for nutrition and medication administration due to severe cognitive impairment and aphasia, did not receive water flushes as ordered between and after medication administration. Observation revealed that only 5 cc of water was used for flushes, rather than the ordered 10-15 cc between medications and 30-50 cc after. The Medication Administration Record (MAR) inaccurately reflected that the correct flushes were given and was signed by a nurse who did not perform the procedure. Both the nurse who administered the flushes and the nurse whose initials appeared on the MAR confirmed the documentation was inaccurate. Facility policies require that all medical record documentation be objective, complete, and accurate, including the administration of medications, treatments, and any changes in resident condition. The Director of Nursing confirmed that only the nurse administering care should document it in the MAR, and that accurate documentation is essential for ensuring appropriate care. The failures in documentation for both residents were confirmed through interviews, record reviews, and direct observation.