Failure to Maintain Accurate and Timely Medical Record Documentation
Penalty
Summary
The facility failed to maintain accurate and timely documentation in the medical record for one resident, resulting in incomplete records and lack of communication regarding care instructions. Specifically, a registered nurse entered a late progress note into the electronic health record after the resident had already been discharged to the hospital, documenting that the head of bed should remain elevated, but this information was not communicated to staff in a timely manner. Additionally, another nurse wrote a late progress note indicating that a physician had been notified about the resident's decreased coughing and wheezing, but the physician confirmed that this notification did not occur. These late entries led to incomplete and inaccurate documentation of the resident's condition and care provided.