Incomplete and Inaccurate Clinical Record Documentation
Penalty
Summary
The facility failed to ensure that clinical records were complete and contained accurate information for multiple residents. For several residents, documentation was missing or inaccurate regarding range of motion (ROM) exercises and bathing, with no evidence that these activities were completed or refused on numerous dates. Interviews with facility management confirmed the absence of required documentation in the residents' records. In other cases, clinical records lacked documentation of significant clinical events and follow-up. One resident experienced low blood pressure and dizziness, but the initial low blood pressure reading, the re-check, and physician notification were not documented, despite staff confirming these actions occurred. Another resident had a physician order for a urinalysis due to suspected infection, but the record did not show that the sample was collected, sent, or refused, nor that the provider was notified of the inability to obtain the sample, as required. Additional deficiencies included the absence of required legal documentation, such as Power of Attorney (POA) and Advance Directives, despite care plans and meeting notes indicating their existence. There were also inconsistencies in documenting the timing and assessment of a resident's fall, with vital signs and neurologic checks not accurately recorded in relation to the incident. Facility staff acknowledged these documentation gaps during interviews.