Failure to Maintain Required Skilled Nursing Documentation
Penalty
Summary
The facility failed to maintain medical records in accordance with accepted professional standards for residents receiving skilled services. For one resident admitted with multiple diagnoses including a femur fracture, history of falls, hypertension, anemia, urine retention, and weakness, there were no skilled nursing notes or skilled progress notes documented during the period skilled services were provided. The Director of Nursing (DON) confirmed that there should have been daily skilled nursing documentation for each day the resident received skilled services, but none were found in the assessment or progress notes sections of the medical record. Another resident, admitted with diagnoses such as metabolic encephalopathy, scalp contusion, history of falls, necrotizing enterocolitis, dementia with mood disturbance, and other conditions, also lacked complete skilled documentation. Skilled notes were only present for the first four days of skilled services, with no further skilled notes or documentation regarding skin condition for the remainder of the skilled service period. The DON acknowledged that the documentation was incomplete for the duration of the skilled services provided.