Incomplete Medical Record for Tracheostomy Care Due to Documentation Error
Penalty
Summary
The facility failed to ensure that a resident's medical record was complete and accurate regarding tracheostomy care. Upon review, it was found that a physician order for tracheostomy care every shift and as needed was entered into the electronic medical record using an option that did not populate the Treatment Administration Record (TAR) or Medication Administration Record (MAR). As a result, the order was only visible in the orders section and not accessible for nurses to document the care provided. Multiple nurses who cared for the resident reported either forgetting to document tracheostomy care or being unable to do so because the order did not appear in the TAR/MAR. The Director of Nursing confirmed that the order was not entered properly, preventing appropriate documentation. The deficiency involved a resident who had been readmitted to the facility and required regular tracheostomy care. Despite the presence of a physician order, the improper entry into the electronic system led to a lack of documentation for tracheostomy care over several months. Staff interviews revealed that nurses performed the care but did not document it due to the missing order in the documentation system, and some only realized the omission during the investigation. The Administrator acknowledged the issue but did not provide an explanation for the failure.