Inaccurate Documentation of Resident Assistance Needs
Penalty
Summary
The facility failed to maintain a complete and accurate medical record for one of two sampled residents when both a Certified Nursing Assistant (CNA) and a Licensed Vocational Nurse (LVN) documented inaccurate information regarding the resident's level of assistance needed for bed mobility and transfers. Specifically, the CNA documented that the resident was dependent on staff for transfers, mobility, getting up in a chair, and ambulation on several dates, but later admitted that this was inaccurate and that the resident actually required only limited assistance for these activities. Similarly, the LVN documented in the resident's discharge summary that the resident was dependent on staff for bed mobility and transfers, but also acknowledged this was inaccurate. The resident involved had a history of cerebral infarction, difficulty walking, and a traumatic brain disorder, and was assessed as moderately impaired in cognitive skills. The Minimum Data Set indicated the resident required supervision or touch assistance for activities such as dressing, bathing, toileting, and personal hygiene. The facility's policy required that all medical records be complete and accurate to reflect the care and services provided, but this was not followed, resulting in incomplete and inaccurate documentation in the resident's medical record.