Inaccurate and Conflicting Nursing Documentation in Resident Medical Record
Penalty
Summary
The facility failed to ensure that documentation in a resident's medical record was factual, accurate, and consistent with accepted professional standards, as required by its policy titled "Documentation in Medical Record" revised 12/19/22. For one resident, the physician progress note dated 1/31/26 documented that the resident was nonverbal, and the MDS assessment indicated severe cognitive impairment. However, multiple nursing progress notes and skilled nursing evaluations from 1/31/26 to 2/2/26 documented that the resident denied pain or discomfort, followed commands, denied weakness, tremors, numbness, or tingling, was alert and oriented x3, communicated verbally with clear speech, and had only mild cognitive impairment with some confusion. These entries conflicted with the physician documentation and MDS findings that the resident was nonverbal and severely cognitively impaired. Additionally, the nursing progress notes contained documentation of nursing care being provided to the resident after discharge. The record showed the resident was transferred to the hospital on 2/2/26 for a low hemoglobin level, yet a nursing progress note dated 2/4/26 documented that the resident was on GT feeding, had a wound vac in place and functioning as ordered, was receiving IV antibiotics, and had no signs of active infection. During an interview and concurrent record review on 2/12/26, the DON acknowledged confusion and inaccuracies in the nursing record, stating that the documentation made it appear the resident was nonverbal on one shift and then alert and talking on the next, and that the resident had left on 2/2/26 so the nurse could not have assessed the resident on 2/4/26. The DON stated it was unclear whether nurses were actually performing assessments or copying and pasting documentation and affirmed that she expected the documentation to be accurate.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.