Inaccurate Post-Discharge Documentation in Resident Medical Record
Penalty
Summary
The deficiency involves the facility’s failure to ensure an accurate medical record for one of eight sampled residents. Facility policy on Nursing Clinical Documentation requires that the clinical record be a concise and accurate account of treatment, care, response to care, signs, symptoms, and progress of the resident’s condition. The resident in question had an H&P indicating no capacity to understand and make decisions. The resident was admitted to the facility and later discharged to the hospital via EMS at 1800 hours on 2/8/26 after becoming very agitated, yelling, and cussing at staff, which led to the sheriff being called and two officers responding. Progress notes for this resident were documented after the resident had already left the facility. One note, timed at 2149 hours on 2/8/26, described the resident’s agitation, involvement of law enforcement, and transfer to the hospital at 1800 hours. Another note, timed at 2303 hours on 2/8/26, documented a head-to-toe assessment under a skilled evaluation by an LVN. During interviews, an LVN verified that these notes were entered after the resident’s discharge and stated that she would not chart on a resident who was no longer in the facility. The MDS Coordinator acknowledged that the 2303 hours progress note should not have been documented after the resident left. The LVN who entered the 2303 hours note stated she was not assigned to the resident, was only helping with documentation, had seen the resident at the start of her shift, and was unaware of the transfer, adding that staff should have checked with nurses and CNAs before writing the notes.
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