Incomplete and Inaccurate Medical Record Documentation
Penalty
Summary
The facility failed to maintain complete and accurate medical records for several residents, as evidenced by missing provider orders, inaccurate documentation, and incomplete recordkeeping. For one resident, oxygen therapy was observed in use on multiple occasions, yet there was no provider order for this therapy in the medical record. The care plan referenced supplemental oxygen, but both the Medical Director and DON confirmed that no order existed for this treatment. Another resident also received supplemental oxygen without a corresponding provider order or adequate monitoring of oxygen saturation, as confirmed by both the Medical Director and DON. In addition, the facility did not ensure the accuracy of informed consent documentation for psychotropic medications. Two residents signed consent forms for psychotropic medications on a date that did not match when the forms were actually signed, as both residents stated they signed the forms on a different day than what was documented. The Quality Assurance Coordinator and Medical Director could not confirm the exact date the provider signed the forms, and the Medical Director acknowledged the possibility of signing blank forms. For another resident, a diagnosis was added to a signed informed consent form after the fact, rather than completing a new form, which the Medical Director stated was not appropriate. The facility also failed to ensure that all relevant assessments and documentation were included in the medical record. For one resident, a dietary assessment was completed on paper with handwritten notes added at various times, but these notes were not dated, timed, or initialed, and the assessment was not included in the electronic medical record. The Kitchen Manager confirmed that assessments were often done verbally and that the paper assessment was not part of the official record. The facility's policy required prompt and appropriate entries in the medical record, including authentication of diagnoses, physician orders, and treatment records, but these requirements were not met in the cited cases.