Failure to Maintain Accurate and Complete Medical Records
Penalty
Summary
The facility failed to maintain complete and accurate medical records for two residents, as evidenced by discrepancies in documentation and assessment following a fall incident. In one case, a resident fell from a recliner in the day room, was witnessed by a nurse, and subsequently complained of left leg pain. Although the progress note indicated that the resident was assessed for physical abnormalities and vital signs while on the floor, video footage revealed that staff did not perform these assessments before moving the resident. The resident was assisted to her feet and walked despite refusing to bear weight on her left leg, and was later found to have a minimally displaced fracture of the left femur. The LPN responsible for the documentation was unable to recall details of the assessment and could not explain where the documented information originated, as confirmed by the DON during an interview. Additionally, there was a discrepancy in the controlled substance record for another resident. The record indicated that Xanax was destroyed, but the DON later confirmed that the medication was actually administered to a different resident. The LPN involved had signed a job description acknowledging the requirement for accurate, contemporaneous charting and completion of medical records in accordance with nursing policies. These failures to accurately document care and medication administration were not in accordance with accepted professional standards and facility policy.