Failure to Maintain Accurate Medical Records
Penalty
No penalty information released
The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.
Summary
The facility failed to maintain complete and accurate medical records for one of nine residents reviewed for abuse or injury of unknown origin. Multiple physician notes for this resident, signed by the Medical Director, documented the presence of bruises on the left cheek and left lower rib cage across several assessment dates. Upon review, the Medical Director acknowledged that these entries were inaccurate, as the resident had experienced bruising only following a fall in a previous month and did not have bruising on the dates documented. The Medical Director confirmed these were documentation errors, resulting in inaccurate medical records for the resident.