Incomplete and Inaccurate Medical Record Documentation
Penalty
Summary
The facility failed to maintain a complete and accurate medical record for Resident #34. Resident #34, who had diagnoses including end stage renal disease, chronic obstructive pulmonary disease, pleural effusion, and type one diabetes mellitus, was admitted to the facility and later discharged to the hospital. Despite the resident not having returned from the hospital, a Legionella signs and symptoms assessment was documented for Resident #34, including vital signs recorded on a date when the resident was still hospitalized. The assessment was completed by an LPN, who could not recall the specifics of completing the assessment for this resident or the source of the information documented. Further review of the resident's census information, progress notes, and MDS assessments confirmed there was no evidence that Resident #34 had returned to the facility at the time the assessment was completed. Observations and interviews with facility staff, including a CNA and the DON, verified that the resident remained in the hospital and that the room was empty. The DON confirmed the assessment's date and content, and the LPN acknowledged completing multiple assessments but could not explain the documentation for this particular resident.