Failure to Maintain Accurate and Complete Medical Records
Penalty
Summary
The facility failed to maintain accurate and complete medical records for multiple residents, as required by accepted professional standards. Several residents using bed rails did not have the necessary physician orders or documented consent from the resident or their representative, despite bed safety evaluations recommending these steps. In some cases, the bed rails were observed in use without the required documentation in the electronic medical record. Additionally, inconsistencies were found in the documentation of residents' code status, with one resident's MOLST form indicating a different resuscitation and intubation preference than what was recorded in the social services assessment. There were also discrepancies in the facility's management of smoking status and supervision requirements. Multiple residents were listed as independent smokers on facility records, while their medical records and care plans indicated they required supervision or were not care planned for smoking at all. In one instance, a resident was observed with cigarettes and a lighter but was not included on the facility's smoker list. Furthermore, the facility's matrix failed to accurately reflect a resident's hospice status, and staff attributed this to a data entry oversight. Additional deficiencies included a failure to update PASRR documentation to reflect current mental health diagnoses for a resident with significant psychiatric history, and inconsistencies in MDS assessments regarding a resident's functional abilities compared to other clinical documentation and staff interviews. There was also a lack of required progress notes documenting side effects of psychotropic medications when indicated by the medication administration record. These lapses in documentation and record-keeping led to inaccurate or incomplete medical records for at least eleven residents reviewed during the survey.