Failure to Maintain Accurate Medical Records and Documentation
Penalty
Summary
The facility failed to maintain complete and accurate medical records for two residents, as evidenced by errors in documentation related to neurological checks and psychiatric medication records. For one resident who experienced a fall, neurological checks were documented with incorrect dates, with entries reflecting dates that did not correspond to the actual event. Despite a correction to one entry, subsequent documentation continued to show inconsistent and inaccurate dates. The DON confirmed the expectation for accurate documentation and acknowledged the issue when it was brought to her attention. For another resident, psychiatric notes inaccurately stated that Seroquel had been discontinued months prior, and therefore a gradual dose reduction (GDR) was not attempted. However, a review of the Medication Administration Record (MAR) did not show an order for Seroquel at the time indicated in the psychiatric notes, and the first order for Seroquel appeared months later. The DON and surveyor confirmed the discrepancies between the psychiatric notes and the MAR, indicating inaccurate documentation regarding the resident's medication history.