Inaccurate Documentation on Hospitalized Resident’s Condition and PRN Narcotic Use
Penalty
Summary
Facility staff failed to maintain accurate and complete medical record documentation for one resident during a hospitalization period. The resident, admitted with diagnoses including Parkinson's disease, Lewy Body dementia, diabetes mellitus, and congestive heart failure, had an MDS indicating intact cognition. Nursing progress notes showed the resident was transferred to a local hospital following an overnight fall and returned to the facility via stretcher several days later. Despite this, Skilled Progress Notes completed by an LPN on three consecutive days during the hospitalization documented that the resident had no change in condition, no cognitive impairment, and was receiving skilled PT, OT, and speech therapy services. These notes also described assessments of neurological/musculoskeletal, skin, cardiac/respiratory, gastrointestinal/genitourinary status, and monitoring for medication side effects, all indicating no new or negative findings. The same Skilled Progress Notes further documented that the resident complained of generalized pain and that PRN Percocet was administered as ordered. However, review of the narcotic count sheets and the MAR for the month showed no Percocet was administered during the period in question. Interviews with the LPN who authored the notes and another LPN confirmed that the resident was hospitalized and not in the facility on the dates when these assessments and medication administrations were charted, and they could not explain why documentation was completed on an absent resident. The Administrator verified there were no discrepancies in the narcotic count sheets. Facility policy on charting and documentation required that medical record entries be objective, complete, and accurate, and made only by licensed personnel in accordance with state law and facility policy, which was not followed in this instance.
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