Incomplete and Inaccurate Medical Records Documentation
Penalty
Summary
The facility failed to maintain complete and accurate medical records for three residents. For one resident, Nurse Practitioner notes in the clinical record referred to another resident, indicating a mix-up or misfiling of documentation. Another resident's diagnosis of Osteoporosis, which was referenced in the care plan and medication orders, was not included in the resident's official diagnoses list or face sheet. Similarly, a third resident's diagnosis of Depression, which was documented in the care plan and progress notes and for which medication was ordered, was not reflected in the diagnoses list or face sheet. These deficiencies were confirmed during an interview with the Director of Nursing, who acknowledged that all diagnoses should be accurately listed on the resident face sheet, as this information is shared with outside medical providers and hospitals. The facility's policy requires that each resident have a separate medical record with prompt and appropriate entries by all healthcare professionals involved in the resident's care.