Failure to Maintain Accurate and Complete 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 accurate and complete medical records in accordance with accepted professional standards for two residents. For one resident, nursing staff did not document Activities of Daily Living (ADL) care after 7:00 AM on a specific date, instead recording that the resident was not available for care, despite evidence that the resident was present in the facility all day. For another resident, the required social history assessment was missing from the medical record, even though the responsible social worker stated that the assessment had been completed. These deficiencies were identified through medical record review and staff interviews during a complaint survey.