Incomplete and Inaccurate Clinical Documentation for Multiple Residents
Penalty
Summary
The facility failed to ensure that clinical records were complete and contained accurate information for several residents, as evidenced by multiple deficiencies in documentation and care planning. For five residents, there were missing or inaccurate entries in the medical records, including lack of provider assessments, incomplete care plans, and discrepancies in medication documentation. In one instance, after a reported altercation between two residents, the clinical record lacked evidence that both residents were assessed by a provider, and the care plans were not updated to reflect new or ongoing behavioral issues. Additionally, documentation for one resident was found to be a direct copy and paste from another resident's note, further indicating incomplete and inaccurate record-keeping. Another resident's clinical record showed inconsistencies regarding the diagnosis and use of psychotropic medication. The record indicated a new diagnosis of schizophrenia without evidence of an evaluation to confirm this diagnosis, and the provider was unable to explain the origin of the diagnosis. Furthermore, the social services documentation inaccurately stated that the resident was not receiving psychotropic medications, despite evidence to the contrary, and the PASRR contained incorrect information about the resident's medical condition. Additional deficiencies were found in the documentation of physician orders and treatment administration. For one resident with a Foley catheter, intake and output measurements and weekly weights were not consistently recorded as ordered. Another recently admitted resident with wounds and diabetes had missing documentation for wound care treatments and insulin administration, with no evidence that treatments were given, held, or refused on several occasions. These findings were confirmed through record reviews and staff interviews, highlighting incomplete and inaccurate clinical documentation for multiple residents.