Failure to Maintain Accurate Medical Records and Follow-Up for Resident Discharge Requests
Penalty
Summary
Surveyors identified that the facility failed to maintain accurate and up-to-date medical records for two residents. Both residents expressed a desire to leave the facility and reported that their requests for assistance with discharge had not been addressed for an extended period. Interviews revealed that the discharge process for one resident had been initiated multiple times but was not completed due to staff turnover. The other resident also reported a lack of follow-up regarding their request to leave. Documentation provided by the current Director of Social Work showed that the last social work notes for these residents were from several months prior, with no follow-up notes available during the period after the previous social worker left. The facility administrator confirmed that there was a gap in social work coverage following the departure of the previous social worker, which resulted in a lack of documentation and follow-up for the affected residents. The current Director of Social Work had only recently started and was unable to provide documentation of ongoing social work interventions for the residents during the interim period. This lapse in maintaining accurate and complete medical records was discussed with the administration team during the exit conference.