Incomplete and Inaccurate Medical Record Documentation for Two Residents
Penalty
Summary
The facility failed to ensure that medical records for two of three sampled residents were complete and accurate, as required by their own policies and accepted professional standards. For one resident, fall risk assessments contained blank entries in critical sections such as systolic blood pressure, vision status, and ambulation on multiple assessment dates. For another resident, the fall risk evaluation was inaccurate regarding the number of medication classes being taken, as the resident was documented as taking fewer classes of medications than were actually prescribed and administered according to the Medication Administration Record (MAR). These deficiencies were confirmed during interviews with facility staff, including an LVN and the Director of Nursing, who acknowledged the incomplete and inaccurate documentation. The facility's policy on charting and documentation requires that records be objective, complete, and accurate, but this standard was not met for the residents in question, potentially impacting the assessment of their care needs.