Inaccurate Medical Record Documentation for Resident
Penalty
Summary
The facility failed to maintain complete and accurate medical records for a resident, as required by accepted professional standards. Specifically, a skilled nurse note documented by an RN incorrectly identified the resident's gender, medical history, and care needs, including stating the resident had a left hip fracture and was recovering from a left hemiarthroplasty, when in fact the resident did not have this diagnosis. The note also included inaccurate information about the resident's cognitive and physical status. This documentation error was discovered when the resident's family requested records upon discharge and noticed the discrepancies. Interviews with facility staff revealed that the RN responsible for the documentation could not explain why the incorrect information was entered, attributing it to high resident turnover and possibly confusing residents while charting. The Director of Nursing and the Administrator were not aware of the inaccurate record until it was brought to their attention. Review of the facility's documentation policy confirmed the requirement for accurate and complete records to ensure proper communication and care.