Failure to Maintain Organized and Accurate Medical Records
Penalty
Summary
The facility failed to maintain an organized and accurate medical record management system, resulting in incomplete and inaccessible resident records. Staff interviews revealed that the individual responsible for medical records was also working as a floor nurse and had not been able to keep up with documentation, prioritizing resident care over paperwork. There was no Director of Nursing (DON) in place, and as a result, essential documentation such as care plans, Minimum Data Sets (MDS), Medication Administration Records (MAR), and Treatment Administration Records (TAR) were not being completed or maintained. Staff reported that care plans had not been generated, and only basic admission evaluations were available, which were not comprehensive or updated. Record reviews for multiple residents showed missing or incomplete documentation, including the absence of MDS assessments, baseline and comprehensive care plans, physician progress notes, activity notes, provider orders, and diagnoses. In one instance, a resident's oxygen orders and CPAP documentation could not be found in the paper chart, and the medical director was unable to locate the necessary orders or explain how staff accessed the information needed for care. The medical director acknowledged a system failure and was unaware of the process for maintaining or reviewing care plans and assessments. Staff interviews further confirmed that no one had assumed responsibility for care plans, fall assessments, or MDSs in the absence of a DON, and the assistant director of nursing was overwhelmed with floor duties and infection control. Facility policy reviews indicated clear requirements for timely and comprehensive assessments and care plans, but these were not being followed. The job descriptions for the DON and medical director outlined responsibilities for oversight and quality assurance of medical records and care planning, but these duties were not being fulfilled. Additionally, the former human resources director reported witnessing falsification of records, including forged signatures on assessments and in-service documentation, and manipulation of time records to falsely indicate RN presence. These actions and inactions led to a breakdown in the facility's ability to safeguard resident-identifiable information and maintain medical records in accordance with professional standards.