Failure to Maintain Accurate Medical Records and Proper Discharge Documentation
Penalty
Summary
Facility staff failed to maintain accurate and complete medical records for a resident, specifically regarding the Notice of Transfer or Discharge form. The resident, who was cognitively intact and able to make decisions, reported that a registered nurse (RN) initially presented a blank discharge notice for signature, which the resident declined to sign until she could review the completed form. The RN left with the form and did not return, and the resident later discovered a signed discharge notice in her discharge packet after leaving the facility. The resident stated she did not sign the form and was not given the opportunity to review or discuss its contents prior to discharge. The Director of Nursing (DON) confirmed that the signature on the discharge notice did not match the resident's known signature and appeared to have been signed by facility staff without any notation indicating it was not the resident's signature or that verbal consent was obtained. Additionally, there were inconsistencies in the resident's fall risk documentation. The initial fall risk assessment, completed by a registered nurse upon admission, was not dated, and there was conflicting information between the fall risk assessment and the nursing documentation regarding whether the resident had experienced a fall in the months prior to admission. The DON acknowledged the discrepancy and noted that accurate and complete documentation is necessary for proper care planning, particularly for fall prevention interventions. Facility policies reviewed indicated that nursing documentation should be clear, accurate, and reflective of the care provided, and that falsification or improper correction of records is not permitted. The policies also required that documentation be complete, relevant, and signed by the person making the entry, with the date and time recorded. The failure to follow these standards resulted in incomplete and inaccurate records for the resident, including a falsified discharge notice and contradictory fall risk information.