Failure to Maintain Complete and Accurate Medical Records
Penalty
Summary
The facility failed to maintain complete and accurate medical records in accordance with accepted professional standards for two residents. For one resident with multiple food and drug allergies, staff did not transcribe a physician's order for Benadryl, nor did they document the assessment or follow-up after the resident experienced an allergic reaction to fish served at lunch. The resident reported symptoms such as swelling and redness of the lips and a funny feeling in the mouth after being served fish, despite having informed staff of his allergy. Interviews with staff and review of the clinical record revealed that no documentation existed for the physician's order, administration of Benadryl, or nursing assessment related to the event. Additionally, there was no care plan addressing the resident's multiple allergies. Another resident's clinical record was incomplete regarding an incident where the resident physically assaulted another resident. Progress notes indicated the resident was placed on 1:1 supervision for physical assault, but there were no details documented about the incident itself. Facility incident summaries and witness statements described the resident punching another resident in the face in the smoking area, resulting in an abrasion to the victim's head. However, the clinical record lacked documentation of the incident's specifics, and there was confusion in the facility's incident summary regarding the identity of the aggressor. Interviews with staff and residents confirmed the occurrence of the assault and the lack of staff presence in the smoking area at the time. The facility's director of nursing acknowledged the documentation errors and the absence of detailed records regarding the incident. The facility's own policy requires thorough documentation of adverse events, including objective findings, measures taken, and patient interpretation, but these standards were not met in either case.