Incomplete and Inaccurate Medical Record Documentation
Penalty
Summary
The facility failed to ensure that medical records were complete and accurate for two residents. For one resident, multiple medications were documented in the Medication Administration Record (MAR) as not given, with the reason coded as 'Other/See Progress Notes.' However, upon review, there was no corresponding documentation in the progress notes explaining why these medications were not administered. Both a registered nurse and the Director of Nursing confirmed that it was expected for such documentation to be present, and that it was missing for the dates in question. The facility's own policy requires documentation to be accurate, relevant, and complete, containing sufficient details about the resident's care and responses to care. For another resident, who had a peripherally inserted central catheter (PICC) line in place for intravenous antibiotic treatment, the physician's order and Treatment Administration Record (TAR) did not specify the site or location of the PICC line. The Unit Manager and the Director of Nursing both confirmed that it was standard practice to document the site of the PICC line in the physician's order and on the TAR, but this information was not present in the resident's clinical record.