A 26-year-old Michigan woman was arraigned on one count each of 2nd degree Vulnerable Adult Abuse and Intentionally Placing False Information in a Medical Record, Michigan Attorney General Dana Nessel announced on October 9, 2023. Each count is a four-year felony.
The Department of Attorney General alleges that during the woman’s employment in 2021 as a Certified Nursing Assistant (CNA) at a skilled nursing facility, she ignored multiple standing orders in relation to a 58-year-old resident’s plan of care during mealtime. Her alleged neglect led to a choking incident at the facility, ultimately resulting in the death of the resident.
Additionally, the CNA is alleged to have made several false medical records entries about the victim’s care while he was receiving life-saving care from EMS and hospital personnel.
“The overwhelming majority of those who provide long-term care in Michigan do so with integrity and respect for their important role,” said Nessel. “But when there is a serious breach in the responsibility entrusted to them, there are criminal consequences, and my office will seek accountability.”
Compliance Perspective
Issue
F805 says that facilities are to provide, and residents are to receive, food prepared in a form designed to meet individual needs according to their assessment and care plan. F808 says that residents must receive and consume foods in the appropriate form and/or the appropriate nutritive content as prescribed by a physician, and/or assessed by the interdisciplinary team to support the resident’s treatment, plan of care, in accordance with his or her goals and preferences. Falsification of documents regarding care, incomplete or inaccurate documentation of care, failure to provide the care documented, or other acts of deception or omission raise serious concerns about an individual’s ability to provide safe nursing care and prevents subsequent caregivers from having a complete and accurate picture of the resident’s care and condition. Falsifying medical records can be viewed as fraud, and quick action should be taken when falsified medical records are discovered.
Discussion Points
- Review policies and procedures on food and nutrition services, individualized restricted diets per physician or designee orders, resident care plans, and emergency response to a resident who is choking. Also review your policies and procedures for following standards of care and requirements for documentation in medical records.
- Educate staff on the various types of meal and beverage consistencies and on appropriate feeding techniques for each. Provide training regarding the importance of following physician orders and individualized care plans, and on what to do in response to a resident who is choking, including proper technique for administering the Heimlich Maneuver if needed. Document that the trainings occurred and place in each employee’s education file.
- Periodically perform audits for accuracy comparing doctors’ orders in the medical record to diet sheets followed by dining services staff. At each meal, ensure that staff audit to ensure residents’ foods and beverages are the correct consistency before serving, and that physician orders and resident care plans are being followed for both meal consistency and provision of assistive devices. Ensure adequacy of supervision and assistance during meal and snack times. Also periodically audit medical records to ensure that documentation is complete, meets standards for content and timeliness, and that entries have not been falsified or erroneously reported in any way.
*This news alert has been prepared by Med-Net Concepts, LLC for informational purposes only and is not intended to provide legal advice.*
