A registered nurse (RN) who worked at a Michigan nursing home was charged on May 17, 2023, with two counts of Medical Records—Intentionally Placing False Information on Chart—Health Care Provider, Michigan Attorney General Dana Nessel announced. The charges are both four-year felonies.
While working at the facility, the RN is alleged to have falsified two medical records of neurological assessments for a resident who had previously suffered a fall in the nursing home and later died. The Michigan Department of Licensing and Regulatory Affairs had requested the documents as part of an on-site visit investigating the fall and subsequent death of the patient.
“Falsifying medical records is often intended to conceal patient neglect,” Nessel said. “Such conduct misleads subsequent caregivers as well as oversight officials and can have disastrous consequences for patients, which is why we take such allegations extremely seriously.”
Compliance Perspective
Issue
Honesty, accuracy, and integrity are imperative for the provision of safe and effective nursing care. Nurses are expected to exhibit honesty, accuracy, and integrity in the provision of care, including performing nursing assessments, reporting changes in condition, acknowledging errors in practice and reporting them promptly, accurately charting and reporting, implementing care as ordered, complying with all laws and rules affecting the practice of nursing, and complying with the minimum standards of nursing. 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 your policies and procedures for following standards of care and requirements for documentation in medical records. Also review policies on cooperation with state investigations. Update as needed.
- Train all appropriate staff on your policies and procedures for following standards of care and meeting regulatory requirements for medical record content as set forth in F842 Medical Records: “Reflect the resident’s condition and the care and services provided across all disciplines to ensure information is available to facilitate communication among the interdisciplinary team. The medical record must provide an accurate representation of the actual experiences of the resident and include enough information to provide a picture of the resident’s progress, including his/her response to treatments and/or services, and changes in his/her condition, plan of care goals, objectives and/or interventions.” Document that these trainings occurred and file the signed documents in each employee’s education file.
- 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.*
