Failure to Maintain Accurate and Complete Medical Records
Penalty
Summary
The facility failed to maintain complete and accurate medical records for one resident who experienced a fall and subsequently required medical attention. The resident underwent an MRI at a local hospital, which revealed an acute, impacted subcapital hip fracture with lateral displacement and extensive soft tissue edema. However, there was no documentation in the resident's medical record indicating the departure from or return to the facility for the MRI. Additionally, there was a gap in documentation between a nurse practitioner's note and a later transfer note, with no record of the MRI event or related care during that period. Further review of the resident's records revealed discrepancies in the administration and documentation of Tramadol, a narcotic analgesic. The narcotic count sheet indicated that several doses were removed from the supply on specific dates, but these administrations were not recorded on the Medication Administration Record (MAR). Pain assessments, as ordered to be completed every shift using a 1-10 scale, were also not properly documented, with nurses signing off on completion but failing to record the actual pain scores. The Director of Nursing confirmed these documentation failures after reviewing the records and speaking with the involved nurses.