Failure to Maintain Accurate and Complete Clinical Records
Penalty
Summary
The facility failed to maintain accurate and complete clinical records for multiple residents. For one resident with confusion, a nursing note documented dental pain and a missing tooth, but there was no evidence in the clinical record that the resident's pain was assessed or that a dental referral was made, despite the DON later providing a dentist's consult report that should have been included in the record. Another resident with paranoid schizophrenia exhibited ongoing hallucinations and paranoia, but there was no documentation that the psychiatrist was informed of these symptoms or that follow-up psychiatric visits occurred, even though the administrator stated that such visits had taken place. Additionally, a cognitively intact resident was scheduled for discharge, but there was no documentation in the clinical record regarding communication with the resident or his family about discharge plans. The resident expressed confusion about his discharge status, and the administrator confirmed that the social worker had communicated with the resident's brother but had not documented it. These omissions demonstrate a failure to maintain clinical records in accordance with accepted professional standards.