Failure to Maintain Complete and Accurate Medical Records
Penalty
Summary
The facility failed to maintain complete and accurate documentation for five of eight residents, as evidenced by missing or incomplete records in the electronic medical record (EMR) and medication administration records (MAR). For several residents, including those with diagnoses such as coronary artery disease, hypertension, diabetes, anemia, hyperlipidemia, constipation, hypocalcemia, Alzheimer's Disease, Parkinson's Disease, depression, and end-stage renal disease, required monthly weights and vital signs were not documented as ordered by physicians and per facility policy. In some cases, the MAR indicated that weights were 'already complete' when no documentation was present in the EMR. Staff interviews, including those with the Registered Dietitian and the Director of Nursing, confirmed that the required documentation was not completed or entered into the EMR for the affected residents. The facility's own policies and job descriptions require that registered nurses record daily care and maintain accurate medical records, but these requirements were not met for the residents identified in the report. Additionally, progress notes for some residents described ongoing behavioral and care needs, such as frequent requests for staff attention and assistance, but the documentation was noted as inaccurate or incomplete by the Director of Nursing. The deficiencies were identified through clinical record review and staff interviews, and were found to be in violation of state regulations regarding the maintenance of medical records and nursing services.