Incomplete and Inaccurate Medical Record Documentation
Penalty
Summary
The facility failed to ensure that medical records were complete and accurate for two residents. For one resident, a physician's order required monitoring and documentation of the number of times the resident attempted to get up unassisted each shift. However, the Monitor Record for this resident had missing entries on several dates and inaccurately recorded zero incidents on days when the resident had actually gotten up unassisted and experienced unwitnessed falls. The Director of Nursing (DON) and a registered nurse confirmed these omissions and inaccuracies, acknowledging that the documentation was not completed as required. For another resident, there were physician's orders for the application and removal of two different lidocaine patches for pain management. The Medication Administration Record (MAR) indicated that the patches were applied and removed as ordered on specific dates and times. However, during an interview, the resident reported not receiving the patches on two days, and the DON confirmed that the patches had not been applied despite being documented as administered on the MAR. These documentation failures were verified through interviews, record reviews, and observations. The facility's own policies required accurate and timely documentation of clinical findings and medication administration, but these were not followed in the cases reviewed. The deficiencies had the potential to result in unmet care needs for the affected residents due to inaccurate medical records.
Plan Of Correction
F0842-Resident Records - Identifiable Information Immediate Corrective Action: On 09/03/25 - In accordance with the facility's general documentation guidelines, Lidocaine patch administration was recorded on the MAR and monitoring getting up unassisted for Resident #8 & #11. All medication errors for the residents identified in the citation were immediately corrected, the physician was notified, and residents were assessed for adverse outcomes. On 09/03/2025 - In accordance with the facility's general documentation guidelines, a count sheet was created to ensure all Lidocaine patches are administered. Residents Affected: On 09/04/2025, the RN Supervisor and designee reviewed the MAR to ensure all Lidocaine patches were administered, complete, accurate, and properly stored. No residents were identified as being affected at this time. Corrective Action: All licensed nursing staff were re-educated/inservice on safe medication administration practices, including the "5 Rights" (right resident, right drug, right dose, right route, and right time). All resident records were audited by the Medical Records Director and DON to verify accuracy, completeness, and proper storage on 09/04/2025. Monitoring of Corrective Action: The DON or their designee will audit 5 random resident records weekly for 4 weeks, then Q2 monthly for 6 months to ensure compliance, focusing on safe practices, documentation accuracy, and proper storage and handling of medication. The results of these audits will be presented to the QAPI Committee on a quarterly basis for further monitoring and/or action planning as needed.