Failure to Accurately Document and Maintain Resident Medical Records
Penalty
Summary
Facility staff failed to accurately document and maintain medical records in accordance with accepted professional standards for multiple residents. In several cases, staff did not properly record whether residents exhibited side effects from anti-anxiety, antipsychotic, antidepressant, and anticoagulant medications. Instead of using the required 'Y' or 'N' documentation to indicate the presence or absence of side effects, staff sometimes used check marks or failed to provide the necessary progress notes when side effects were indicated. This was observed in the records of residents with diagnoses such as dementia, anxiety, depressive disorder, and those receiving medications that require close monitoring for adverse effects. Additionally, there were discrepancies and errors in the documentation of residents' medical status. For example, one resident's Treatment Administration Record did not reflect the required observation status for antipsychotic medication monitoring, and another resident's progress note incorrectly stated a recent hospitalization that did not match the actual hospitalization date provided by the DON. These inaccuracies resulted in medical records that did not accurately reflect the residents' current status or medical history. The facility also failed to ensure that advance directive documentation was complete and accurate. In one instance, a resident's advance directive was missing essential information such as dates and witness signatures, despite a progress note indicating the document had been completed and filed. These deficiencies were identified through medical record reviews and staff interviews, where staff acknowledged the documentation errors and omissions.