Inaccurate Medical Record Documentation Due to Shared EHR Credentials
Penalty
Summary
The facility failed to maintain complete and accurate medical records for all 15 residents reviewed, as required by professional standards. Certified Nursing Assistants (CNAs) documented care activities such as personal hygiene, bathing, incontinent care, oral care, and positioning under the electronic health record (EHR) credentials of other staff members, including Licensed Vocational Nurses (LVNs) and other CNAs. This occurred because some staff members' credentials were not working, and they either used saved log-ins on facility computers or obtained credentials from coworkers. For example, one CNA documented care under an LVN's credentials, which were saved on the computer, while another CNA used a coworker's credentials after requesting them directly. Staffing schedules confirmed that the staff members whose credentials were used were not present during the times the documentation was entered. Interviews with staff and administration revealed that staff were aware they were not permitted to use another person's credentials, but some did not realize this constituted false documentation. The facility's policy required documentation to be objective, complete, and accurate, and prohibited sharing or saving credentials in a way that would allow others to document under the wrong name. The Director of Nursing (DON) and Administrator confirmed that sharing or saving credentials for others to use was not acceptable practice, and that the facility's policy did not allow for such actions.