Failure to Maintain Complete and Accurate Medical Records
Penalty
Summary
Facility staff failed to maintain complete and accurate medical records for several residents, as evidenced by multiple deficiencies identified during record review and interviews. For one resident who sustained a left ankle fracture, the medical record did not contain any physician documentation regarding the injury, despite confirmation of the fracture by x-ray and hospital evaluation. The Medical Director's review and conclusion that the fracture was pathological due to underlying osteopenia and disuse atrophy were not documented in the resident's record. Additionally, the facility was unable to provide documentation of the Medical Director's findings or report in the resident's medical record. In another instance, the facility did not maintain a copy of a resident's death certificate in the medical record following the resident's death. The DON acknowledged that the death certificate should have been included in the resident's record and indicated that it had to be requested from the funeral home. These findings demonstrate that the facility did not ensure that resident medical records were complete and accurately documented in accordance with accepted professional standards.