Failure to Maintain Complete and Accurate Medical Records for Residents
Penalty
Summary
The facility failed to maintain complete and accurate medical records for multiple residents, as required by accepted professional standards. Specifically, physician orders were not clear or accurate, assessment documents did not accurately reflect resident conditions, behaviors were not properly monitored, personal inventories were not updated or available, informed consents were not signed or dated, and resident inventory lists were incomplete. For several residents with complex medical conditions, including diabetes, documentation of podiatry consults and services was either missing from the records or not scanned in a timely manner. For example, one resident's podiatry consult was not scanned into the record until several months after the service, and another resident's consult was not present in the record at all. Staff interviews confirmed that consults were not consistently entered into the residents' records as required. Record reviews for both sampled and supplemental residents showed that documentation supporting podiatry services was absent for a significant number of residents who had received such services. Staff confirmed that these records were not available in the residents' files, despite the services having been provided. The lack of complete and accurate clinical records placed residents at risk of not having their needs met, as there was no documentation to support that necessary medical services had occurred.