Nurse Falsifies Medical Records While Offsite
Penalty
Summary
A licensed nurse, identified as staff member B, failed to uphold professional standards of nursing care by falsifying medical record documentation and health information for ten out of nineteen sampled residents. Staff member B documented treatments, assessments, and monitoring in the Treatment Administration Records (TARs) for multiple residents on a specific date, despite not being present in the facility to perform these tasks personally. This was confirmed through interviews with other staff members, who reported that staff member B was not in the building and instead completed charting from home, citing personal reasons for her absence. Record reviews revealed that staff member B charted a variety of nursing interventions and monitoring activities, such as skilled notes, wound care, medication monitoring, and behavioral assessments, for several residents. However, corresponding progress notes for these interventions were missing for the date in question, further supporting that the documented care was not actually provided by staff member B. Other staff members expressed concerns and suspicions about the accuracy of staff member B's documentation, with one nurse stating she was unable to complete her own charting due to staff member B's actions. The facility's employee handbook and documentation policy explicitly prohibit falsifying company records and require that documentation be factual, objective, and based on first-hand knowledge. Staff member B's actions were in direct violation of these policies, as she recorded information in the medical records without having performed the assessments or treatments herself. This resulted in inaccurate and misleading documentation for a significant number of residents.