Inaccurate Resident Records Due to Shared EMR Credentials
Penalty
Summary
Staff failed to ensure the accuracy and integrity of resident medical records for six out of nine residents reviewed. Documentation in the electronic medical record (EMR) showed that staff members recorded care activities such as bed mobility, toileting, bowel and bladder elimination, turning and positioning, and meal consumption for multiple residents. However, interviews revealed that the staff who documented these activities were not always the ones who provided the care. For example, one CNA's credentials were used by others to document care provided to residents, and another CNA admitted to using a colleague's credentials because she had forgotten her own. Additionally, a CNA was documented as providing a bed bath to a resident on a specific date, but in an interview, she stated she did not care for that resident on that day, and another CNA confirmed she had provided the care but used someone else's credentials to document it. Further interviews with staff, including CNAs and supervisory personnel, confirmed that sharing EMR credentials and documenting under another staff member's login was occurring. The corporate nurse and CNA supervisor both acknowledged that staff credentials should remain confidential and that staff should not document in the EMR using another person's credentials. These actions resulted in inaccurate and unreliable resident records, as the documentation did not accurately reflect who provided care or when it was provided.