Failure to Document Key Resident Events in Medical Records
Penalty
Summary
The facility failed to maintain complete and accurate medical records for three residents by not documenting key events such as admission, discharge, or death. For one resident, there was no progress note documenting her admission, including the time of arrival, condition, or care needs, despite her profile page indicating the admission date. The Director of Nursing (DON) confirmed that a progress note should have been written at the time of admission, and attributed the omission to the admission occurring after normal business hours. Another resident's medical record lacked documentation regarding the circumstances of his death, including how he was found, the time of death, and notifications made, even though the Minimum Data Set (MDS) indicated a death in the facility. Similarly, a third resident's record did not include a nurse's note about his discharge home, such as the time of departure, who accompanied him, or his condition at discharge, although all required discharge notices were issued. Staff interviews confirmed that nurses were responsible for these entries and were unable to explain the omissions.