Incomplete and Inaccurate Medical Record Documentation
Penalty
Summary
The facility failed to maintain complete and accurate medical records for several residents, as required by its own policies and professional standards. For one resident, the most current POLST (Physician Orders for Life-Sustaining Treatment) form was not uploaded into the electronic health record, and a previous POLST form indicating a different code status was not voided. This resulted in conflicting information regarding the resident's code status, as the electronic record showed a full code while a physician's order indicated DNR (Do Not Resuscitate). The Medical Records Director confirmed that the current POLST form was not uploaded because she had not yet accessed the binder, and the previous form remained in the record unvoided. Additionally, documentation for turning and repositioning, personal hygiene, oral hygiene, toileting hygiene, and pressure reduction was incomplete or missing for multiple residents, including those with severe cognitive impairment and total dependence on staff for ADL (Activities of Daily Living) care. Reviews of documentation survey reports revealed numerous missing entries across various shifts, with some tasks incorrectly coded as 'not applicable' or left blank. Interviews with the DON and ADON confirmed that CNAs were expected to document care at the end of their shifts and that missing or incorrect documentation could indicate that care was not provided or not properly recorded. The facility's policies required that all procedures and treatments be documented with specific details, including the date, time, care provided, and the staff member responsible. However, for several residents, these requirements were not met, as evidenced by the missing or incomplete documentation in their records. The DON and ADON verified these findings during interviews and acknowledged that the documentation did not meet facility standards.