Incomplete Medical Record Documentation and Missing Incident Reports
Penalty
Summary
The facility failed to ensure that medical records for three residents were complete and accurate, as required by professional standards. For two residents, documentation of showers was incomplete, with records showing only two showers documented in the past 30 days, despite care plans indicating the need for showers twice a week. Both residents reported receiving showers as scheduled and had no complaints, but the records did not reflect this care. Additionally, for one resident with severe cognitive impairment and a history of falls, incident reports for two separate falls were missing from the records, even though progress notes described the incidents and subsequent actions taken. Interviews with staff revealed issues with access to the electronic charting system, leading to lapses in documentation of both baths and incident reports. The Assistant Director of Nursing acknowledged that some staff could not access the charting system, and that incident reports were sometimes completed by hand and not entered into the system. Furthermore, the facility was unable to provide policies regarding documentation practices, as the transition to new ownership had left staff without access to previous policies or clear guidance on documentation requirements.