Incomplete and Inaccurate Medical Record Documentation for New Admission
Penalty
Summary
The facility failed to maintain a complete and accurate medical record for one resident who was newly admitted with diagnoses including respiratory failure and chronic obstructive pulmonary disease (COPD). The resident was admitted in a confused state and was dependent on staff for eating, personal hygiene, grooming, and was incontinent of bowel and bladder. Despite these needs, there was no documentation of assistance with activities of daily living (ADLs) or nursing services provided to the resident from 7 p.m. to 12:30 a.m. on the day of admission. Interviews with facility staff, including a registered nurse supervisor and the director of staff development, confirmed that there was no record of nursing rounds or CNA care for the resident during this period. Both staff members acknowledged that documentation should have been completed to reflect the care provided, such as rounds, assistance with ADLs, and the resident's condition during the shift. The lack of documentation meant that it was unclear what care, if any, was provided to the resident during this time. Facility policies reviewed indicated that all services, observations, and changes in a resident's condition must be documented objectively and completely in the medical record. The policies also specified that residents unable to perform ADLs independently should receive appropriate support and that all such care should be recorded. The failure to document the care and services provided resulted in an incomplete and inaccurate medical record for the resident.
Plan Of Correction
F 842 Accurate and Complete Resident Records Corrective Action: RN responsible for the documentation for resident is no longer employed at the facility. CNA responsible for the ADL documentation for resident 1 is no longer employed at the facility. On 6/26/25, DSD provided in-service to the Licensed nurses and CNAs regarding the importance of accurate, complete, and timely documentation of all care provided including ADL assistance with emphasis on new admissions to prevent inaccurate and incomplete documentation. Identification of Other Residents at Potential Risk: On 6/25/25, Medical Records designee reviewed all new admission charts from the last 30 days to ensure complete, timely, and accurate documentation from the licensed nurses and CNAs to reflect all care and assistance provided. No other gaps or inaccuracies were identified; no other residents were found to be affected or at risk. Measures to Prevent Recurrence: Medical Records designee to audit the medical record of all new admissions within 72 hours to ensure timely, accurate, and complete documentation is in place. The findings will be submitted to the DON or designee for immediate corrective action and re-education as needed. On 6/26/25, DSD provided in-service to the Licensed nurses and CNAs regarding the importance of accurate, complete, and timely documentation of all care provided including ADL assistance with emphasis on new admissions to prevent inaccurate and incomplete documentation. Medical Records designee to conduct a monthly audit of all current resident charts to ensure timely and complete documentation and all necessary assessments are in place including care and ADL assistance. Immediate corrective action and re-education to be provided as needed. ADON or designee to review all new admission charts within 72 hours to ensure residents are provided appropriate ADL care and assistance with accurate documentation in place. Immediate corrective action will be provided as needed. Monitoring of Performance: The DON or designee will conduct weekly audits of 5 random resident charts for 4 weeks then monthly for 2 months, ensuring nursing and ADL care documentation is present, timely, complete, and accurate. The findings from the audit will be reported to the QAPI Committee monthly for 3 months for review and recommendations to ensure compliance is achieved and maintained.