Incomplete Clinical Documentation and Communication Failures
Penalty
Summary
The facility failed to maintain complete and accurate clinical records for multiple residents, resulting in deficiencies related to documentation and communication. For one resident with severe vascular dementia and a history of frequent falls, the clinical record did not contain evidence that the family was contacted to discuss goals of care after a significant change in condition, as indicated in the provider's note. Additionally, after the resident experienced an unwitnessed fall, there was no documentation that neurological checks were performed, despite facility policy and staff acknowledgment that such checks are required and should be recorded. Another resident with congestive heart failure and an indwelling Foley catheter had provider orders for daily weights and output monitoring, as well as catheter care and monitoring for signs of infection. The clinical record lacked evidence that daily weights were consistently obtained or documented, and there were multiple shifts where output measurements were not recorded. Staff interviews confirmed that these required assessments and documentation were not completed as ordered. A third resident, recently admitted with severe protein calorie malnutrition and adult failure to thrive, had multiple progress notes indicating that palliative and hospice consults were discussed and planned with the family. However, the clinical record did not contain evidence that these consults were actually obtained or ordered prior to the resident's death. Staff interviews revealed uncertainty about whether referrals were made and indicated that the resident's participation in skilled services delayed the hospice referral, which was not documented clearly in the progress notes.