Failure to Maintain Complete and Accurate Medical Records
Penalty
Summary
Facility staff failed to maintain complete and accurate medical records for three residents. For one resident, documentation showed assessments dated after the resident had already been discharged, with staff acknowledging that these entries should have been marked as late entries but were not, resulting in an inaccurate record. Facility policy requires documentation to be completed at the time of service or, if late, clearly marked as such, which was not followed in this instance. Another resident's medication administration record (MAR) indicated a Fentanyl patch was administered, but the narcotic sign-off sheets and nurse's notes revealed the medication was not available and not given, indicating an error in documentation. Additionally, for a third resident who experienced a change in condition and was transferred to the hospital, the clinical record lacked documentation of the interventions performed, such as administration of Narcan, oxygen, and chest compressions, despite the nurse confirming these actions were taken. These failures resulted in incomplete and inaccurate medical records for the affected residents.