Inaccurate Nursing Documentation for Resident Assessment
Penalty
Summary
The facility failed to ensure accurate nursing documentation for one resident when a Registered Nurse (RN) incorrectly recorded respiratory distress symptoms, including difficulty breathing, shallow respirations, sternal retractions, and shortness of breath while lying flat, in the resident's Nurse Advance Skilled Evaluation. During a review, the RN acknowledged that the documentation was entered in error and was actually intended for another, unidentified resident. The Director of Nursing (DON) confirmed that nursing documentation should be accurate, as outlined in the facility's policy and procedure for nursing documentation, which requires records to be concise, clear, pertinent, and accurate. This inaccuracy in documentation had the potential to result in inappropriate care for the resident, as the recorded symptoms did not reflect the resident's actual condition at the time.