Failure to Maintain Accurate and Complete Medical Records
Penalty
Summary
The facility failed to maintain complete and accurate medical records for several residents, as required by its own policies and accepted professional standards. For multiple residents, there were inconsistencies between their capacity to make medical decisions as documented in their History & Physical (H&P) examinations and what was recorded on their admission face sheets. Specifically, some residents who were determined to lack capacity were incorrectly listed as self-responsible on their admission records, and updates to H&P examinations were not made after changes in cognitive assessments. Additionally, a resident's Advance Directive Acknowledgment form did not accurately reflect the existence of a completed POLST, despite one being present in the record. The facility also failed to ensure the accuracy of medication orders and documentation of clinical monitoring. One resident's physician order for metoprolol tartrate included an incorrect hold parameter for systolic blood pressure, which was verified by nursing staff as a documentation error. Furthermore, for two residents who had indwelling urinary catheters removed, the facility did not document urine output or use the bladder scanner to assess for urinary retention as required by facility policy. Instead, only check marks were recorded on the Treatment Administration Records (TARs), without accurate measurements of urine output or post-void residuals. These documentation failures were confirmed through interviews with nursing staff and the Director of Nursing, who acknowledged the discrepancies and lack of accurate record-keeping. The facility's own policies require factual, accurate, and complete documentation, but these standards were not met in the cases reviewed, resulting in incomplete or inaccurate medical records for the affected residents.