Incomplete and Inaccurate Medical Records in Nutrition Assessment
Penalty
Summary
The facility failed to maintain complete and accurate medical records for a resident, as required by accepted professional standards. Specifically, the nutrition assessment form for the resident contained the correct name but listed an incorrect admission date, date of birth, height, and ideal body weight range. The dietician, who completed the assessments, acknowledged crossing out and correcting the height and ideal body weight range but was unaware that the admission date and date of birth were incorrect. The dietician also reported experiencing computer issues during this process. Additionally, the resident's care plan and dietary care plan contained handwritten changes and lacked clear dating for some interventions. The resident involved had a history of dementia with behavioral disturbances, diabetes, and vitamin D deficiency, and was noted to have severe cognitive impairment, poor appetite, and significant weight loss. The DON confirmed that having incorrect information in the nutritional assessments could result in not having an accurate weight and dietary assessment for the resident. The facility's medical records policy was requested but not provided by the time of the survey exit.