Incomplete Medical Record Documentation for Resident with Change in Condition
Penalty
Summary
The facility failed to maintain a complete and accurate medical record for one resident, as required by its own policies and accepted professional standards. Specifically, the Elopement Evaluation form for the resident, dated 5/2/25, was found to have several sections left blank, including those addressing the pattern and impact of wandering behavior, risk identification, goals, interventions, and clinical suggestions. This incomplete documentation was confirmed during a review of the closed medical record with the Director of Nursing (DON), who acknowledged that the form should have been fully completed. Additionally, the resident experienced a change in condition, including agitation, physical aggression, striking out at staff, and attempts to leave the facility, as documented on the eINTERACT tool. However, there was no documentation in the medical record indicating that the resident was monitored for this change in condition during the 0700-1500 hours shift on 5/3/25. The DON verified that the required progress note for monitoring during this period was missing. The facility administrator also acknowledged these findings.