Inaccurate Documentation of Pain Reassessment and Catheter Care
Penalty
Summary
The facility failed to maintain accurate medical records for one resident, specifically regarding pain reassessment and indwelling catheter care. During a continuous observation period, it was noted that the resident's medication administration record (MAR) and treatment administration record (TAR) were incomplete at the start of the observation. Although the records were later marked as completed for both pain reassessment and catheter care, direct observation confirmed that the nurse did not return to the resident's room to perform a pain reassessment or provide catheter care after the initial administration of as-needed pain medication. The resident confirmed in an interview that no catheter care was provided that morning and that pain reassessment was not consistently performed after receiving pain medication. A review of the progress notes indicated documentation of a pain reassessment that, according to both observation and the resident's account, did not actually occur. The director of nursing acknowledged that the time care was documented in the TAR did not necessarily reflect when the care was provided and that staff were encouraged to document as accurately as possible. However, the evidence showed that documentation was completed for care and assessments that were not actually performed, resulting in inaccurate medical records for the resident.