Failure to Maintain Complete and Accurate Medical Records
Penalty
Summary
The facility failed to maintain complete and accurate medical records in accordance with accepted professional standards for multiple residents. For one resident, there was no documentation verifying that the resident was repositioned at least every two hours, and staff records did not specify whether the resident was dressed, only the type of assistance provided. The Director of Nursing (DON) acknowledged the lack of documentation and stated that staff had recently begun signing off on tasks, but the records still did not confirm that required care was provided. In another case, a resident's medical record showed inconsistent and inaccurate documentation regarding bowel movements, with discrepancies between task documentation and progress notes. Additionally, a third resident had a care plan for elopement risk initiated without corresponding documentation of exit-seeking behavior in the medical record, and the behavior was not coded in the Minimum Data Set (MDS) assessment due to lack of documentation. These findings demonstrate that the facility did not ensure medical records were complete, accurate, and reflective of the care provided.