Failure to Maintain Accurate and Timely Medical Records
Penalty
Summary
The facility failed to maintain complete, accurate, and timely medical records for three sampled residents, as required by accepted professional standards. Certified Nursing Assistants (CNAs) did not document the percentage of food consumed by three residents at the correct times, instead recording meal intake percentages for multiple meals at the same time or before the meals were actually consumed. Additionally, there were instances where meal intake was not documented at all for certain meals. The Director of Staff Development (DSD) confirmed that these entries were inaccurate and should have been completed after the meals. For one resident, a CNA documented a bowel movement's appearance without direct observation, intending to verify with the resident later, which did not align with proper documentation practices. Furthermore, a Registered Nurse (RN) did not complete and sign a Change in Condition Evaluation (CIC) for the same resident after an incident where the resident could not be located in the facility. The Director of Nursing (DON) acknowledged that documentation should be accurate and timely, and that these failures resulted in incomplete and inaccurate records. The facility's own policy and procedure, last reviewed in January 2025, required that medical record entries be recorded promptly as events occur, be complete, legible, descriptive, and accurate, and never be documented before the event. The observed practices did not comply with these requirements, resulting in inaccurate information in the medical records of the affected residents.