Failure to Maintain Accurate and Complete Medical Records
Penalty
Summary
The facility failed to maintain complete and accurate medical records for a resident by not ensuring that physical therapists and nursing staff accurately documented the resident's pain location in both physical therapy encounter notes and the medical record. Specifically, two physical therapists documented the resident's pain as being in the left lower extremity, but later clarified that the pain was actually in the right lower extremity. Additionally, the licensed vocational nurse did not assess or document the pain location when administering pain medication on multiple occasions, and the medication administration record lacked this critical information. Further, the facility did not document the rationale for a room transfer for the resident. While the social services director and admissions coordinator acknowledged that the resident was moved to another room and that the family was notified, neither could recall or provide documentation of the reason for the transfer. The facility's policy required comprehensive documentation of social service assessments and interventions, including reasons for room changes, but this was not followed in this instance. The resident involved had a complex medical history, including a recent right femur fracture, dementia, osteoarthritis, and generalized muscle weakness. The resident required significant assistance with activities of daily living and had a history of falls and pain management needs. The lack of accurate and complete documentation in the resident's medical record resulted in incomplete information that could affect the resident's care, as noted by staff during interviews and record reviews.