Failure to Maintain Accurate and Complete Medical Records
Penalty
Summary
The facility failed to maintain accurate and complete medical records in accordance with accepted professional standards for multiple residents. In several cases, cognitive assessments such as the Brief Interview for Mental Status (BIMS) were either incorrectly scored or not completed properly, leading to inconsistent documentation of residents' cognitive status. For example, one resident's BIMS score was entered as 99, indicating the interview could not be completed, yet the assessment showed the resident was able to answer questions, suggesting severe impairment. Additionally, smoking safety screens for these residents contained conflicting or missing information regarding cognitive loss and dexterity, with some questions left blank or answered inaccurately. Another deficiency was identified in the documentation of care provided, such as bathing. For one resident, the electronic medical record indicated a shower was given, while the corresponding shower sheet documented a bed bath instead, showing a discrepancy in the records. This inconsistency in documentation raises concerns about the accuracy of care records and the facility's ability to track the actual care provided to residents. Medication administration records also revealed deficiencies. A resident reported not receiving medications on time or at all, and a review of the electronic medical record and medication administration audit showed that medications were often administered and documented at times significantly later than ordered. Despite the medication administration record indicating that medications were given, the audit revealed delays and inconsistencies in the timing of administration and documentation. These findings demonstrate a failure to maintain accurate, timely, and complete medical records for residents, as required by professional standards.