Incomplete and Inaccurate Medical Record Documentation for Two Residents
Penalty
Summary
The facility failed to maintain complete and accurate medical records for two of six residents reviewed. For one resident, staff did not correctly document admission medications and linked a diagnosis of depression to the use of amitriptyline, despite no documented history of depression or delirium in the resident's records. The nurse practitioner acknowledged that the diagnosis of depression was not found in the hospital records and that the medication was continued without a corresponding diagnosis. Additionally, the resident's son requested discontinuation of antipsychotic medications, which was noted by the nurse practitioner, but the medications were not discontinued as intended. For another resident, there were inconsistencies in the documentation of a stage three pressure ulcer. While the initial skin assessment indicated the presence of the ulcer and treatments were initiated, subsequent daily skilled assessment progress notes and weekly skin assessments inconsistently documented the presence of the pressure ulcer, with some notes indicating 'No' or omitting documentation of the wound. The director of nursing and nurse consultant confirmed discrepancies in the clinical record documentation regarding the pressure ulcer.