Inaccurate Documentation of Resident Drain Tubes
Penalty
Summary
The facility failed to ensure that resident medical records were accurately documented in accordance with professional standards of practice. For one resident admitted for care following sepsis and multiple liver abscesses, there were inconsistencies in the documentation of the number of abdominal drain tubes present. Interventional Radiology notes indicated the removal of specific drains on certain dates, but progress notes from nursing staff continued to document an incorrect number of drains for several days following these procedures. For example, after the removal of drain #1 and later drain #2, progress notes still reflected the presence of three drains, and only later adjusted to two and then one drain as per the actual clinical situation. The Director of Nursing confirmed that multiple progress notes contained inaccurate information regarding the number of drains, attributing the errors to nurses potentially copying and pasting previous notes rather than updating them to reflect the current clinical status. This resulted in inaccurate clinical documentation for the resident, as the medical record did not consistently match the resident's actual condition and the interventions performed.