Failure to Maintain Accurate and Complete Medical Records
Penalty
Summary
The facility failed to maintain accurate and complete medical records for a resident who was admitted with multiple diagnoses, including villonodular synovitis pigmented, major depressive disorder, quadriplegia, and a documented diagnosis of morbid obesity. During interviews and record reviews, it was found that the resident had a wound on the left forearm requiring daily dressing changes per physician's orders. However, the Treatment Administration Record (TAR) for this wound care was left blank on several dates, indicating a lack of documentation for the required treatment. Additionally, a review of the resident's medical record with the Registered Dietitian revealed an inaccurate diagnosis of morbid obesity, as the resident had never been obese according to the RD, despite the diagnosis being present in the record.