Incomplete Medical Records for Three Residents
Penalty
Summary
Kadima Rehabilitation and Nursing at Cheswick was found to be non-compliant with federal and state regulations regarding the maintenance and documentation of resident medical records. Specifically, the facility failed to ensure that medical records were complete and accurately documented for three residents. The deficiency was identified during an abbreviated survey conducted in response to a complaint. The survey revealed that the facility did not complete the required initial admission assessments by social services for three residents who were admitted in late January 2025. The residents involved had significant medical conditions, including alcoholic cirrhosis of the liver, chronic kidney disease, hepatic encephalopathy, orthopedic aftercare, absence of a limb, alcohol-induced chronic pancreatitis, fracture of the tibia, protein-calorie malnutrition, and polyosteoarthritis. Despite these complex medical needs, the facility's failure to conduct initial social service assessments meant that crucial aspects of their care planning and documentation were incomplete. This oversight was confirmed by the Nursing Home Administrator during an interview with surveyors.
Plan Of Correction
1. The facility will correct that Social Services did not complete initial admission assessments for 3 of 7 residents. Social Service will complete an initial admission assessment for R1, R2, and R3. 2. The facility will ensure that Social Services completes an initial admission assessment on new admissions timely. The Social Service Director will look back at every new admission since January 1st to confirm if they have an initial assessment completed. If any are found to not have one completed, one will be completed if the resident is still a current resident. 3. The NHA will educate the Social Service Director on F-842 with emphasis on completing an initial admission assessment on every new admission timely. 4. The NHA/Designee will audit every new admission for 3 months to ensure a Social Service admission assessment was completed timely. The results of these audits will be reported to the Quality Assurance Performance Improvement Committee for review, recommendations, and frequency of audits. 5. Date of compliance 2-10-25