Failure to Maintain Accurate Medical Records and Documentation
Penalty
Summary
Facility staff failed to maintain complete and accurate medical records in accordance with accepted professional standards for two residents. One resident, admitted with a displaced closed fracture of the left tibia, reported regular right leg pain and delays in staff response to call bells, resulting in prolonged periods of pain. Both the resident and their spouse stated that pain medication was received 30 to 60 minutes after being requested on two occasions, and the medication administration record (MAR) did not document the administration of PRN Tylenol on those dates. Additionally, the MAR included an order for pain assessment every shift, but there were issues with timely medication delivery and documentation. Another resident, admitted with multiple diagnoses including hemiplegia, hemiparesis, seizures, and diabetes, experienced an unwitnessed fall. The initial Fall Risk Scoring Tool assessment completed after the fall did not include the resident's predisposing diagnoses of stroke and seizures, nor did it account for the use of antiseizure medication or the current fall history. This resulted in an inaccurate assessment of the resident's fall risk, which was later corrected after the surveyor raised concerns. A further deficiency was identified regarding the documentation of code status for the same resident. The electronic medical record contained conflicting information, with a physician's note and a MOLST form indicating DNR/DNI status, while an active physician's order listed the resident as Full Code. This inconsistency in the resident's code status documentation was confirmed by the DON during the survey.