Incomplete and Inaccurate Medical Record Documentation
Penalty
Summary
The facility failed to maintain complete and accurate medical records for three residents, resulting in deficiencies related to documentation of oxygen administration, misfiled nursing notes, and inaccurate discharge information. For one resident, the electronic medical record contained a nursing progress note that was intended for a different resident, and this error was not identified prior to the survey. Additionally, the documentation of oxygen administration for two residents was inconsistent and incomplete across multiple record-keeping systems, including nursing notes, vitals reports, and respiratory administration records. There were missing assessments, discrepancies in the timing and documentation of oxygen use, and a lack of clarity regarding when oxygen was administered or discontinued. Interviews with facility leadership confirmed that the records did not provide sufficient information to determine the accurate use of PRN oxygen and that required assessments were missing. For another resident, a complaint of shortness of breath and subsequent oxygen administration was documented in a unit communication book but was not entered into the resident's official nursing progress notes. The nursing notes for that day did not reflect the resident's complaint or the intervention provided, and the DON confirmed that this documentation should have been included in the progress notes. This omission resulted in an incomplete medical record for the resident. A third resident received a Notice of Discharge that inaccurately stated her health had improved sufficiently to no longer require facility services, despite therapy and assessment records indicating a decline in her condition and ongoing need for skilled nursing care. Interviews with the social worker and administrator revealed that the discharge notice did not accurately reflect the resident's true condition, and the administrator acknowledged marking the form incorrectly. The facility's own documentation policy requires that records be timely, accurate, objective, thorough, and complete, but these standards were not met in the cases reviewed.