Incomplete Documentation of Resident Treatments in Medical Records
Penalty
Summary
The facility failed to ensure that medical records were complete and accurately documented for two sampled residents. For one resident with multiple diagnoses including type 2 diabetes mellitus, end stage renal disease, and dependence on renal dialysis, the Treatment Administration Record (TAR) for a specific month showed missing documentation by licensed nurses on several treatment orders. These included monitoring and treatment of skin scrapes, swelling, discoloration, pitting edema, and application of topical medications. The missing documentation occurred on multiple dates and shifts, and was confirmed by the Treatment Nurse, who stated that blank entries on the TAR indicated the treatment was not done or not documented. The Director of Nursing also verified the missing documentation and stated that it was her expectation for nurses to carry out and document all treatment orders. For another resident with a history of cellulitis and a stage 3 pressure ulcer on the coccyx, the TAR showed missing documentation for daily and as-needed wound care treatments. On certain dates, there was either no documentation or incomplete entries, such as a note to check progress notes without follow-up documentation that the treatment was completed. The nurse assigned to the resident during one of the missing documentation periods confirmed that the treatment was performed but not documented on the TAR as required. The Director of Nursing reviewed the records and confirmed the lack of documentation for the pressure ulcer treatments. The facility's policy on nursing documentation requires that records specify what interventions were performed, by whom, when, and where, and that documentation be clear, concise, and accurate. The failure to document treatments as ordered resulted in incomplete medical records for both residents, as confirmed by multiple staff interviews and record reviews. This deficiency was identified through interviews with nursing staff and review of the facility's documentation policies.