Failure to Maintain Accurate Clinical Records and Documentation
Penalty
Summary
The facility failed to maintain accurate and complete clinical records for one resident by not ensuring that nursing staff properly documented medication administration and related progress notes. Specifically, a Licensed Vocational Nurse (LVN) documented a code '9' on the Medication Administration Record (MAR), which indicates that a progress note should be present to explain why a medication was not given. However, no such progress note was found in the resident's record, resulting in incomplete documentation. Additionally, after the resident was discharged to a general acute care hospital, another LVN did not accurately document in the MAR, further contributing to the inaccuracy of the resident's medical records. The resident involved had multiple complex medical conditions, including type 2 diabetes mellitus, hypertension, a gastrostomy tube, and chronic kidney disease. The resident's care plan included numerous orders such as enteral feeding, medication administration via g-tube, pain monitoring, and regular assessments for side effects and symptoms related to their diagnoses and treatments. The MAR for this resident showed that tasks and medication administrations were signed off as completed, but the required supporting documentation, such as progress notes for exceptions or withheld medications, was missing. Interviews with facility staff, including the Director of Nursing (DON) and the LVNs involved, confirmed that the documentation was incomplete and did not meet professional standards. The DON acknowledged that the absence of accurate documentation could result in an incomplete record and hinder continuity of care, as subsequent staff would not have a clear understanding of the resident's condition or the reasons for any deviations from the care plan. The facility's own policy required complete, legible, and accurate entries in the medical record, which was not followed in this instance.