Failure to Ensure Accurate and Timely Medical Record Documentation
Penalty
Summary
The facility failed to ensure accurate and timely documentation in the medical records for two of three residents reviewed. For one resident with multiple complex diagnoses, including chronic respiratory failure, severe malnutrition, COPD, dementia, and dependence on a respirator, nursing progress notes were not documented at the time of care but were instead created or corrected hours or days later. Several notes were struck out, sometimes without a reason, and documentation of the resident's death was not completed properly at the time of the event. Staff interviews confirmed that a new LPN did not feel she documented the death properly and was assisted by the ADON, but there was no evidence of falsification. The facility's policy requires documentation to be completed at the time of service or by the end of the shift, which was not followed in these instances. For another resident with diagnoses including dementia, morbid obesity, ESRD, DM2, OSA, and hypertension, physician orders for chest physiotherapy and oral suctioning were not accurately documented as completed. The medication administration record (MAR) showed missed administrations, with chart codes indicating the resident was deceased or out of the facility, even though the resident was alive and not transferred until later. Staff interviews confirmed the inaccuracies in the documentation. These findings demonstrate a failure to maintain accurate and timely medical records in accordance with professional standards and facility policy.