Incomplete and Inaccurate Medical Record Documentation for Enema Order and Bathing Care
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete, accurate, and timely medical records for a resident with dementia, Parkinson’s disease, colostomy status, major depressive disorder, and a need for assistance with personal care. The resident’s quarterly MDS showed moderate cognitive impairment and a need for substantial/maximal assistance with bathing. On one date, an LVN documented in a nurse’s note that a new order was received for a one-time enema and daily MiraLAX for constipation. The electronic medical record and discontinued orders, however, only contained the MiraLAX order and did not include any physician or NP order for the enema. During interview, the LVN stated she had received a verbal order from the NP to give the enema, could not recall if she entered the order into the electronic record, and acknowledged the importance of having the enema order documented in the record to show when it was given and whether it was effective. The facility also failed to maintain complete bathing documentation for the same resident. Initial review of the resident’s bathing record showed showers on four specific dates only. A later review of the updated bathing documentation showed additional entries indicating a bed bath on another date, a refusal of bathing on a separate date, and a notation that bathing was not applicable on yet another date, all originally missing from the record. CNAs reported they regularly provided showers and were trained to document baths and showers in the electronic medical record. The DON confirmed that the resident’s showers had not been updated in the medical record and that the bathing documentation should have been current. Facility policies required that ADL care, including bathing, be documented at the time of service or by the end of the shift, and that each resident’s medical record contain complete, accurate, and timely documentation of assessments, observations, and services provided.
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