Inaccurate Clinical Documentation in Resident Medical Record
Penalty
Summary
The facility failed to maintain accurate and complete clinical records for one resident, as required by accepted professional health information management standards. Specifically, the resident's clinical record included provider notes documenting symptoms of eye redness, a diagnosis of conjunctivitis, and treatment with erythromycin ointment. However, a review of the resident's list of medical diagnoses did not include conjunctivitis, and there were no corresponding physician orders or medication administration records indicating that erythromycin was ever ordered or administered. During interviews, both the Director of Nursing (DON) and the Nurse Practitioner (NP) stated they did not recall the resident experiencing eye redness, and the NP confirmed that the documentation regarding conjunctivitis was entered in error. The facility's policy requires that a medical record be maintained for every person admitted, in accordance with accepted professional standards and practices. The inaccurate documentation in the resident's clinical record represents a failure to meet these standards.