Failure to Accurately Document Resident Conditions and Treatments
Penalty
Summary
Surveyors identified that the facility failed to maintain accurate and complete medical records for multiple residents, resulting in documentation that did not accurately reflect residents' conditions, treatments, and responses. For one resident with a history of femur fracture, multiple myeloma, and heart failure, a wound care note documented multiple wounds on the lower extremities, feet, and buttocks, with corresponding treatments. However, Daily Medicare Notes completed by a registered nurse on the same and following day incorrectly stated that the resident had no wounds, despite ongoing wound care being provided. Interviews with nursing staff confirmed the presence of wounds and questioned the accuracy of the nurse's documentation. Additionally, two other residents who were prescribed antibiotics for conditions such as conjunctivitis and respiratory infections had no nursing progress notes documenting their condition before, during, or after antibiotic treatment. Medical provider notes indicated the need for antibiotics based on clinical findings, but nursing documentation failed to provide a record of the residents' status or response to treatment. Staff interviews confirmed that such documentation should have been present to reflect the residents' progress and the rationale for antibiotic use.