Failure to Maintain Accurate and Complete Medical Records
Penalty
Summary
The facility failed to maintain complete, accurate, and readily accessible medical records for two residents. For one resident with chronic obstructive pulmonary disease and asthma, there were discrepancies between physician orders, treatment administration records (TAR), and progress notes regarding oxygen therapy. The physician ordered a change from 3 liters per minute (L/min) to 2 L/min of oxygen, but this change was not transcribed into the official physician orders. The TAR continued to reflect administration of 3 L/min, while progress notes documented administration of 2 L/min on several occasions. Additionally, refusals of oxygen therapy were not consistently documented, and notifications to the physician were based on verbal reports rather than written documentation. Nursing staff and the director of nursing acknowledged that the medical record was inaccurate due to these inconsistencies. For another resident with chronic kidney disease, cellulitis, diabetes, and heart failure, there was a lack of documentation regarding the discontinuation of an antibiotic prescribed after a hospital visit. The hospital after visit summary included an order for Augmentin, but the facility's electronic health record (EHR) showed a verbal order for the medication with a start and stop date, without any corresponding written order or physician note explaining the discontinuation. Staff interviews revealed uncertainty about the process for retrieving and incorporating outside medical records into the facility's EHR, and the director of nursing confirmed that the record did not address the discontinuation of the antibiotic. The facility's medical record policy required documentation according to the resident's level of care and for any unusual activity, event, or change in assistance. However, the lack of accurate transcription of physician orders, inconsistent documentation of care provided, and unclear processes for integrating external medical records led to incomplete and inaccurate records for the residents involved.