Inaccurate Documentation of Substance Use History on Admission Assessment
Penalty
Summary
Facility staff failed to maintain complete and accurate medical records for one of two sampled residents when the substance use history section of the admission nursing assessment was inaccurately documented. The resident was admitted in January 2026 with diagnoses including sepsis, acute osteomyelitis of the right ankle and foot, and type 2 diabetes mellitus. The acute hospital history and physical dated 1/15/26 documented a history of recent methamphetamine use. However, the facility’s admission nursing assessment dated 1/16/26 indicated under the substance use history section that the resident had never used drugs, creating conflicting information between the hospital record and the facility’s assessment. During interviews and concurrent record reviews, the Social Services Director confirmed that the resident had a history of drug use and acknowledged that this information had been missed when reviewing the record. The Social Services Director stated that a care plan and psychiatric consultation were not completed for the resident. The Assistant Director of Nursing confirmed the discrepancy between the hospital H&P and the admission nursing assessment and stated that the licensed nurse responsible for the admission assessment documented it incorrectly. The ADON further stated that staff often complete these assessments incorrectly because they are rushing. Review of facility policy indicated that documentation in the medical record is required to be objective, complete, and accurate, and the LVN job description requires maintaining accurate and up-to-date medical records, including nursing assessments and care plans.
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