Incomplete and Inaccurate Medical Documentation for Resident Monitoring Devices and Interventions
Penalty
Summary
The facility failed to ensure that medical documentation was complete and accurate for two residents, which had the potential to affect all residents. For one resident with multiple complex diagnoses, including severe cognitive impairment and a history of falls, there were inconsistencies and omissions in the documentation of ankle monitor placement and compression stocking use. Physician orders specified the ankle monitor should be placed on the left ankle and checked for function and placement, but staff documented checks on the left leg while the device was actually on the right leg. There was no documentation of the device being moved, and staff were unaware of the conflicting orders. Additionally, staff documented daily application and removal of compression stockings, but interviews revealed the resident frequently refused them, and there was no documentation of these refusals. Family and staff interviews confirmed the resident often did not wear the stockings and that the ankle monitor caused a wound on the right ankle, which was not reflected in the records. For another resident with dementia and other chronic conditions, the care plan and physician orders required staff to check the placement and function of an ankle monitor on the right ankle every shift. However, review of the Treatment Administration Record showed missed documentation on several shifts. Furthermore, an LPN admitted to documenting that the function and placement of the ankle monitor were checked without actually knowing how to check the device's function. The device used to check the monitor's function was found without batteries, and the LPN was instructed on its use only after the deficiency was identified. Facility policy required that all services provided, progress toward care plan goals, and changes in condition be documented objectively, completely, and accurately in the medical record. Despite this, there were clear lapses in documentation, including failure to record refusals of care, inaccurate reporting of device placement, and incomplete or inaccurate documentation of required monitoring. These deficiencies were confirmed through record review, staff and family interviews, and direct observation.