Inaccurate Skin and Medication Documentation in Resident Medical Record
Penalty
Summary
The deficiency involves the facility’s failure to maintain an accurate and complete medical record for a resident with multiple serious medical conditions. The resident was admitted with diagnoses including metabolic encephalopathy, a stage 4 sacral pressure ulcer, and unspecified dementia, and was documented as having severely impaired cognitive skills and total dependence on staff for activities of daily living, with bowel and bladder incontinence. An admission reassessment documented pressure ulcers on the left heel and sacrococcyx, and the MDS indicated two unstageable pressure injuries present on admission. Subsequent skin documentation was inconsistent and inaccurate. A Skin Issues record dated 12/11/2025 indicated one stage 3 sacrococcyx pressure ulcer, while a Skin Issues record dated 1/6/2026 indicated four stage 3 pressure ulcers and one stage 4 pressure ulcer. During interviews and concurrent record review, the Treatment Nurse stated that the 1/6/2026 Skin Issues entry was not accurate and that the resident had only one stage 4 sacrococcyx pressure ulcer. The Treatment Nurse and a Registered Nurse both acknowledged that this inaccurate documentation made the medical record inaccurate and could cause confusion in care. The facility’s Charting and Documentation policy required that documentation in the medical record be objective, complete, and accurate. The facility also failed to accurately document medication administration for this resident while the resident was hospitalized. The resident’s orders included Depakote three times daily, Mirtazapine at bedtime, and Potassium chloride daily. The resident was transferred to a general acute care hospital on 1/14/2026 and returned on 1/19/2026. However, the January MAR showed that one LVN documented administration of Depakote on 1/15/2026 at noon, and another LVN documented administration of Mirtazapine, Potassium, and Depakote on 1/16/2026 at various times, despite the resident being in the hospital on those dates. The MDS nurse confirmed that check marks on the MAR indicated medications were administered and stated this documentation was incorrect because the resident was not in the facility. Nursing staff and the Registered Nurse Supervisor stated that nurses are supposed to verify that residents are in the facility, verify identity, and sign the MAR after actual medication administration, in accordance with the facility’s Charting and Documentation and Administering Medications policies, which require accurate recording of medications administered.
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