Incomplete and Inaccurate Medical Record Documentation
Penalty
Summary
The facility failed to ensure that a resident's medical record was complete and accurate, resulting in care being planned and delivered based on incorrect assessments. Specifically, a licensed nurse reported texting a physician to clarify the resident's medication administration route, but there was no documentation of this communication in the resident's medical record. Additionally, the resident's Medicare Skilled Charting did not reflect the skilled nursing services provided, such as diabetic care and enteral feeding care, as required. The Bed/Side Rail Entrapment Risk Assessment inaccurately indicated that alternatives to bed/side rails had been attempted, when in fact, no such alternatives were tried. Further review of the Medication Administration Record revealed that the same blood pressure readings were recorded for both lying and sitting positions over several days, which a nurse confirmed was inaccurate. The Director of Nursing also acknowledged that the charting was inaccurate upon review of the relevant records. The facility's own documentation policy requires that relevant findings be accurately documented in the clinical record, which was not followed in these instances.