Failure to Maintain Accurate and Complete Clinical Records for Two Residents
Penalty
Summary
The facility failed to maintain complete and accurate clinical records for two residents, resulting in documentation that did not reflect the actual care provided. For one resident with a history of dementia, gastro-esophageal reflux, hypertension, Parkinson's disease, and seizure disorder, the care plan required tube feeding via a G-tube. The Medication Administration Record (MAR) indicated that the resident received tube feedings as ordered on a specific date, but video evidence and family observation revealed that the resident was disconnected from the feeding pump for approximately 11 hours. The nurse responsible documented that the feedings were given, despite the resident not receiving them during that period. In another case, a resident with heart failure, hypertension, hypothyroidism, and a colostomy had physician orders for wound care to be performed three times a week. The Treatment Administration Record (TAR) for this resident showed multiple blank entries on days when wound care was ordered, and there was no alternative documentation in the progress notes to indicate that the treatments were provided. The wound care nurse acknowledged that she was supposed to document each treatment but was unaware that her documentation was not appearing on the TAR. The DON confirmed that documentation was missing and that she had not recently provided staff training on documentation practices. These failures resulted in clinical records that did not accurately represent the care provided or the residents' medical conditions and needs. The lack of accurate documentation was confirmed through interviews, record reviews, and direct observation, including review of video footage and resident interviews. The facility's own policy required proper documentation of medication administration and treatments, which was not followed in these instances.