Failure to Maintain Adequate Medical Records and Documentation
Penalty
Summary
The facility failed to ensure that the medical records for two residents contained sufficient and adequate information in accordance with accepted professional standards. For one resident with severe cognitive impairment, a history of falls, and a risk for elopement, the clinical record did not include a detailed account of an elopement event. While a progress note documented physician communication regarding the elopement, there was no further progress note detailing the specifics of the event, such as the time, summary, or the resident's condition. Additionally, the incident report related to the event was not properly linked within the electronic health record due to formatting issues, resulting in incomplete documentation. For another resident with severe cognitive impairment and dependent on staff for mobility and transfers, the clinical record lacked adequate documentation and follow-up assessments for multiple skin injuries. After a skin tear was identified, there was no further documentation of skin assessments or the healing process. Similarly, when bruises and another skin tear were later noted, the required skin condition reports and follow-up assessments were missing from the record. The facility's process for documenting and closing out skin injuries was not consistently followed, and there was no policy in place guiding staff documentation practices. The facility's Skin Management Guide required that skin alterations be evaluated and documented by a licensed nurse, with a specific form initiated upon identification of a skin injury and used for ongoing documentation. However, this process was not adhered to, resulting in incomplete medical records for the residents involved. The lack of comprehensive documentation for significant events and injuries constituted a failure to maintain medical records in accordance with professional standards.