Inaccurate Medical Record Documentation by Nursing Staff
Penalty
Summary
The facility failed to maintain complete and accurate medical records for a resident, as required by accepted professional standards. Specifically, a nurse entered progress notes indicating that vital signs were taken at a time when the resident was not present in the facility. The nurse documented that vitals were taken at 10:31 AM, but the resident had left the facility earlier that morning and did not return until after the time recorded for the vitals. Additionally, the nurse admitted to documenting the assessment at an incorrect time and not labeling the entry as a late entry, which is contrary to facility policy. The nurse also acknowledged making errors in documenting the resident's continence status and the timing of the vital signs due to being in a hurry. Interviews with the nurse, DON, and Administrator confirmed that the documentation did not accurately reflect the resident's condition or the timing of care provided. The facility's documentation policy requires all entries to be factual, accurate, complete, and current, but this standard was not met in this instance. The inaccurate documentation could lead to confusion among the interdisciplinary team regarding the resident's care and condition.