Incomplete and Inaccurate Medical Record Documentation
Penalty
Summary
The facility failed to ensure the accuracy and completeness of medical records for two residents. For one resident with severe cognitive impairment and multiple diagnoses including diabetes, dementia, and schizophrenia, the Advance Directive Acknowledgement form was found incomplete, as neither option indicating whether an advance healthcare directive had been executed was checked. This omission was confirmed during a review with the Minimum Data Set Coordinator, who acknowledged the missing information on the form. For another resident, also with severe cognitive impairment and several medical conditions such as diabetes, schizophrenia, bipolar disorder, and Parkinson's disease, a physician's progress note was dated after the resident's discharge. The Director of Nursing verified the discrepancy, noting that the physician often enters notes in batches, which may have led to the error. The physician later confirmed that the incorrect dating was likely a mistake due to high patient turnover. Facility policy requires that all entries, including late entries, be accurately dated in the medical record.