Failure to Maintain Complete and Accurate Medical Records
Penalty
Summary
The facility failed to maintain complete and accurate medical records for all seven residents reviewed, as evidenced by missing or incomplete documentation regarding bathing, behavioral incidents, and telehealth appointment attempts. For multiple residents, scheduled bath or shower documentation frequently indicated refusals or was marked as 'not applicable,' yet corresponding progress notes lacked explanations for these refusals or the reasons for the 'not applicable' entries. Facility policy required that refusals and interventions be documented, but this was not consistently done. Additionally, staff interviews confirmed that documentation of refusals and interventions was often omitted, and supervisors were not always notified as required. In the case of a resident with no cognitive impairment but significant physical care needs, there was a lack of documentation regarding behavioral incidents and refusals of care. Staff described episodes where the resident refused to use a mechanical lift for transfers, became combative, and refused assistance with toileting and hygiene. Despite these events, there were no corresponding progress notes or behavior documentation in the resident's record for the relevant period. The care plan also did not reflect the use of the mechanical lift until months after the resident began requiring it, and staff acknowledged that these behaviors and refusals should have been documented according to facility policy. Another resident's record lacked documentation of failed attempts to arrange telehealth appointments with a specialist. The resident reported being informed by the facility that the specialist discontinued services due to missed appointments and that the clinic was uncooperative in setting up telehealth visits. Management confirmed that communication with the clinic occurred but admitted that documentation of these efforts was not completed. These omissions in recordkeeping are contrary to accepted professional standards and the facility's own policies.