Incomplete and Inaccurate Medical Record Documentation
Penalty
Summary
The facility failed to maintain complete, accurate, and systematically organized medical records for several residents, as required by policy and regulatory standards. For three residents reviewed, there were multiple omissions in Medication Administration Records (MAR) and Treatment Administration Records (TAR), including missing documentation of medication administration, behavior and side effect monitoring, anti-coagulant bleeding monitoring, hours of sleep, weekly skin checks, and pain assessments. These omissions were noted across several months and shifts, making it unclear whether prescribed care and monitoring were provided as ordered by physicians. Additionally, for one resident, the facility did not follow up on a PASRR evaluator's identification of an erroneous diagnosis of bipolar disorder, which originated from a hospital record. The incorrect diagnosis remained in the resident's medical record, MAR, and care plan, despite the evaluator's findings. Interviews with staff revealed a lack of awareness regarding the documentation errors and the absence of ongoing documentation audits at the time of the survey.