Failure to Accurately Document Care and Medication Administration
Penalty
Summary
The facility failed to ensure accurate and complete documentation in resident medical records, affecting multiple residents. For several residents, including those with complex medical histories such as obstructive hypertrophic cardiomyopathy, myasthenia gravis, and pressure ulcers, there was a consistent absence of documentation to support that daily living cares were provided on multiple days and shifts. Task sheets for these residents often lacked entries for personal hygiene and other activities of daily living, despite their dependence on staff for these tasks. Interviews with the administrator confirmed these documentation gaps for the reviewed periods. In one case, a resident's narcotic count sheets indicated that tramadol was removed and presumably administered on specific days, but there was no corresponding documentation in the medication administration record (MAR) as required by facility policy. The LPN responsible admitted to only documenting administration on the narcotic count sheet and not in the MAR, even though the resident confirmed receiving the medication. Facility policy clearly stated that all administered medications must be documented in the MAR, which was not followed in this instance. Additionally, for a former resident with multiple wounds and a history of sepsis and kidney disease, the treatment administration record (TAR) indicated that wound care was completed on certain days. However, an internal investigation revealed that two nurses had signed off on wound care that was not actually performed, and failed to document the resident's refusal of treatment. Both nurses were disciplined for falsifying electronic medical record documentation, which led to misleading records indicating that care was provided when it was not. Facility policy required that wound treatments be documented in accordance with physician orders, including the effectiveness of the treatment, which was not done in these cases.