Incomplete and Inaccurate Documentation of Change in Condition, Hospital Transfer, and PRN Medication
Penalty
Summary
The deficiency involves the facility’s failure to maintain a complete and accurate medical record for one resident in accordance with accepted professional standards and its own policies. The resident was admitted with diagnoses including age-related osteoporosis, unspecified dementia with severely impaired decision-making, and essential hypertension. Physician orders included Tylenol 325 mg, two tablets every four hours as needed for mild pain or general discomfort. On a documented change of condition evaluation, the resident complained of right hip pain, was given Tylenol, and the attending physician was notified, resulting in an order for a right hip x-ray. The resident’s change of condition and subsequent assessment were not documented in a timely or accurate manner by the RN. The RN stated she assessed the resident after the change of condition on one day, but the assessment was documented in the progress notes on the following day without being identified as a late entry. The Director of Nursing confirmed that the progress notes should have indicated that this was a late entry and that documentation was not completed by the end of the assigned shift, contrary to the facility’s documentation policy requiring prompt, dated, timed, and signed entries and clear identification of late entries. Additional inaccuracies were identified in the social services and medication administration documentation. Social services documented that the resident was transferred to a general acute care hospital on one date, while both the RN and the Director of Nursing stated the transfer actually occurred the following day. Furthermore, the RN reported witnessing an LVN administer two tablets of Tylenol 325 mg to the resident for right hip pain, but there was no corresponding entry on the medication administration record for that dose. This lack of documentation conflicted with the facility’s policies requiring that each medication administered be recorded on the MAR and that all entries be complete, accurate, and promptly recorded.
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