Failure to Maintain Accurate Clinical Records and Documentation
Penalty
Summary
Facility staff failed to maintain complete and accurate clinical records for three residents. For two residents with PEG tubes, staff signed off in the treatment administration record (TAR) that an anchor device was in place each shift, as required by active physician orders. However, direct observation revealed that no anchor or securing device was present for either resident. Interviews with nursing staff and the DON confirmed that anchors were not being used for PEG tubes, and staff were unaware of the physician orders requiring them. One LPN stated she believed she was signing off on the presence of a different device, not the anchor. The DON was not aware of the physician orders and acknowledged that orders should be followed if present. For a third resident who attended off-site dialysis three times weekly, the facility failed to document the resident's departures and returns for dialysis sessions in the clinical record. There was also no documentation of dialysis communication forms being uploaded into the clinical record, as required by facility policy. Review of the sign-out book and the dialysis communication book revealed no entries regarding the resident's dialysis appointments or communication with the dialysis center.