Inaccurate Documentation of Respiratory Care in Resident Medical Record
Penalty
Summary
The facility failed to maintain complete and accurate medical records for a resident with multiple complex diagnoses, including acute and chronic respiratory failure, congestive heart failure, obesity, end stage renal disease, hypertensive heart disease, sleep apnea, and COPD. According to physician orders, the resident was to be connected to a BiPAP machine during sleep and have it removed upon waking. However, documentation on the Treatment Administration Record (TAR) indicated that the BiPAP was removed every morning, including on a specific date when the resident had thrown the BiPAP machine on the floor the previous night, rendering it nonfunctional. The nurse's note from that night documented the incident and stated that the resident remained on continuous oxygen via nasal cannula instead of BiPAP. Interviews with nursing staff and the Director of Nursing (DON) confirmed that the TAR was inaccurately completed by the LVN, who documented removal of the BiPAP in the morning despite the device not being in use overnight. The LVN acknowledged the error, stating she should have documented the removal and replacement of the nasal cannula instead. The DON and Administrator both confirmed that medical records are expected to accurately reflect the care and services provided, and the facility's policy requires complete and accurate documentation for each resident.