Incomplete and Inaccurate Medical Records for Two Residents
Penalty
Summary
The facility failed to maintain complete and accurate medical records for two residents. For one resident, the medical record did not include full documentation of all diagnoses and psychiatric history, specifically omitting a historical diagnosis of schizoaffective disorder. Although the psychiatric nurse practitioner received records from the resident's community provider indicating a long history of schizoaffective disorder, this information was not entered into the facility's medical record or reflected in progress notes. The diagnosis was later added to the record following a hospitalization, but supporting documentation was not present in the medical record at the time of survey. Staff interviews confirmed that relevant documents were not filed appropriately and the medical record did not accurately reflect the resident's history or diagnoses. For another resident, the electronic medical record contained documents belonging to other residents, including an inpatient order and a provider progress note for two different individuals. Staff interviews revealed that these documents were incorrectly uploaded into the wrong resident's record by facility personnel. The Director of Nursing confirmed that these documents should have been filed in the correct residents' records and not in the affected resident's file.