Inaccurate Medical Record Documentation Due to Improper EMR Access
Penalty
Summary
The facility failed to maintain medical records in accordance with accepted professional standards and practices, resulting in incomplete and inaccurate documentation for one resident. Specifically, a newly hired RN, who did not have her own login credentials for the electronic medical record (EMR) system, was allowed to document an assessment note for a resident using an LVN's profile. The progress note in question was electronically signed and time-stamped under the LVN's credentials, although the content was authored by the RN. The RN stated she was shadowing the LVN to learn the computer system and was permitted to use the LVN's profile, but the LVN was not present when the documentation was entered and was unaware that the RN was making entries in the medical record. The LVN later discovered the note and reported it to the Director of Nursing (DON). Interviews with facility staff revealed that the RN was new, had not been fully trained, and was not authorized to chart independently. The Assistant Director of Nursing (ADON) and DON both confirmed that documentation under another staff member's credentials was not permitted and constituted a violation of facility policy, which requires that entries in the medical record be objective, complete, accurate, and only recorded by licensed personnel under their own credentials. The resident involved was an elderly female with multiple diagnoses, including urinary retention, type 2 diabetes mellitus, and hypertension. The incident resulted in inaccurate attribution of documentation in the resident's permanent medical record.