Incomplete and Inaccurate Medical Records for Nutrition and UTI Evaluation
Penalty
Summary
The deficiency involves failures to maintain complete and accurate medical records for two residents. For one resident with neuropathy, sick sinus syndrome, dysphagia, congestive heart failure, urogenital implants, acute kidney failure, and anxiety disorder, the care plan identified potential for altered nutrition and ordered house supplements and diet per physician orders. A weight change note documented that this resident’s weight had decreased to 121 pounds, reflecting a 15.7% loss in 30 days and 10% in 90 days, and a frozen nutritional treat supplement twice daily with weekly weights was recommended and ordered. The MAR showed the frozen nutritional treats as started and consistently documented as 100% consumed twice daily. However, direct observation of a lunch meal showed that no frozen nutritional treat was on the resident’s tray, the meal ticket did not list the supplement, and the CNA confirmed it had not been provided. The RN who documented 100% intake of the frozen nutritional treat acknowledged making that entry, and the Dietary Director confirmed that frozen nutritional treats had not been sent to the resident during the month, demonstrating inaccurate documentation of supplement administration. For another resident with multiple sclerosis, refractory anemia, centrilobular emphysema, and mild persistent asthma, the medical record showed the resident was cognitively intact but totally dependent on staff for ADLs, had an indwelling catheter, and was occasionally incontinent of urine and always incontinent of bowel. The record documented a positive urine dipstick for leukocytes and/or nitrate, followed by two urine cultures that were reported as contaminated with more than three organisms and included lab instructions to follow up if clinically indicated. There was no documentation in the medical record of any follow-up, evaluation, or intervention related to the positive dipstick results, the contaminated cultures, or the resident’s reported abdominal pain, and no laboratory results for the positive dipstick were present in the chart. An LPN confirmed that no follow-up was completed and that there was no documentation addressing these findings, indicating incomplete and inaccurate medical records regarding possible infection.
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