Incomplete and Inaccurate Medical Record Documentation
Penalty
Summary
The facility failed to ensure complete and accurate documentation of medical information for two of nine sampled residents. For one resident, there were multiple instances where intake, output, and eating percentage documentation were either missing or incorrectly recorded. Physician orders required monitoring and documenting intake and output every shift, but several entries were left blank or marked as 'not applicable' without justification. Similarly, eating percentages were either not documented or recorded inaccurately. The Director of Nursing confirmed that these omissions and incorrect entries were due to missed charting and acknowledged that the documentation was not accurate. For another resident, the facility did not document an incident in which the resident spilled hot tea on her left thigh. Although the event was verbally reported to nursing staff and the resident was evaluated and treated for redness and later blisters, there was no corresponding documentation in the medical record regarding the incident on the day it occurred. Staff interviews confirmed that the incident was not documented, and the required change of condition process was not initiated at the time of the event. Facility policies required that all services, changes in condition, and incidents be documented objectively, completely, and accurately in the medical record to facilitate communication among the interdisciplinary team. The lack of documentation for both the intake/output monitoring and the incident involving the hot tea spill resulted in incomplete clinical records for the affected residents.