Inaccurate Medical Record Documentation for Mediport Care
Penalty
No penalty information released
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Summary
The facility failed to ensure the accuracy of medical records for one resident who had a mediport in place. Medical record review showed that there was an order to flush the resident's implanted port monthly, which was incorrectly documented as completed daily over several months, rather than only on the scheduled date. Additionally, after the mediport was surgically removed, staff continued to sign off the order as completed for several days, despite the port no longer being present. The Director of Nursing confirmed that the order should not have been signed off unless the procedure was actually performed and that documentation should have ceased after the port's removal.