Failure to Accurately Document Medical Records and Notification Times
Penalty
Summary
The facility failed to maintain accurate and timely medical records for a resident, as required by professional standards. Specifically, documentation errors were identified in the resident's electronic health record (EHR), including incorrect times recorded for when the resident and his family received copies of the baseline care plan, and for when the family and physician were notified of a fall. Additionally, progress notes entered by a registered nurse after the resident's discharge reflected times that did not correspond to when the assessments actually occurred, as the nurse documented information after the fact without adjusting the time entries. The resident involved was an elderly male admitted with multiple diagnoses, including hemiplegia, cerebral infarction, and mobility issues, and was at risk for falls. He experienced a fall during his stay, and the documentation of notifications to his family and physician was inaccurately timed. The resident was later transferred to the hospital for an altered mental state, and subsequent nursing notes were entered into the EHR after his discharge, with times that did not reflect when the care was actually provided. Interviews with facility staff confirmed that the inaccurate documentation was due to a lack of awareness regarding the expectation to enter assessments at the point of care and to adjust times when documenting retrospectively. Staff acknowledged that inaccurate medical records could negatively impact resident care, and the facility's policy required all documentation to be complete, accurate, and properly dated and timed.