Failure to Maintain Accurate and Complete Medical Records
Penalty
Summary
The facility failed to ensure the accuracy and completeness of medical records for three residents. For one resident, an incident report documented a significant fall with injuries, including a laceration, hematoma, and fractures. However, the resident's subsequent fall risk evaluation incorrectly indicated no history of falls within the past six months, despite the recent incident. The Director of Nursing acknowledged the inaccuracy in the fall risk assessment. Another resident had multiple physician orders for wound care, including specific instructions for the sacrum and right lateral thigh. The Treatment Administration Records (TAR) for this resident showed several dates with missing documentation for wound care treatments. The wound care nurse noted that the resident sometimes refused care, but since the nurse had been providing care, there were no refusals. The Director of Nursing confirmed that treatment records should not have blanks and that refusals or care provided should be documented accordingly. A third resident's Medication Administration Record (MAR) indicated that aspirin was not administered due to nausea, but the progress note only mentioned that the medication was not on hand and that the provider would be contacted. Interviews with the DON and the nurse involved revealed inconsistencies in documentation regarding whether the provider was contacted and the resident's subsequent status. The DON stated that the nurse should have documented her follow-up actions, and the Regional Nurse Consultant noted the absence of a documentation policy.