Falsification of Medical Record Regarding Catheter Securement Device
Penalty
Summary
The facility failed to ensure the accuracy and integrity of a resident's medical record, resulting in falsified documentation. A review of the medical record for a resident with multiple diagnoses, including paraplegia and chronic kidney disease, showed that the care plan required a urinary catheter securement device to be in place, and physician orders directed staff to monitor the device daily and every shift. The Treatment Administration Record (TAR) for the month indicated that nurses documented the securement device as being in place every shift. However, direct observation revealed that the resident did not have a catheter securement device, and both the resident and her husband reported that she had never had one while at the facility. Staff interviews confirmed the absence of the device, and an LPN admitted to documenting in the electronic medical record that the securement device was present and monitored, despite knowing it was not. This action was in direct violation of the facility's policy requiring objective, complete, and accurate documentation in the medical record.