Failure to Maintain Complete and Accurate Medical Records
Penalty
Summary
The facility failed to maintain complete and accurate medical records for multiple residents, as evidenced by missing documentation in medication and treatment administration records, as well as the absence of incident and behavior reports. For one resident with significant medical needs, including paralysis, stroke, and tube feeding, there were several instances where administration of medications, pain assessments, insulin, blood sugar checks, and wound care were not documented in the Treatment Administration Record (TAR). Interviews with nursing staff and management confirmed that if documentation was missing, it was assumed the care was not provided, and that such omissions could have significant consequences for the resident's health. In another case, a resident with a history of sexually inappropriate behavior and listed on the sex offender registry was placed on 1:1 observation after an incident involving another resident. However, there was no documentation in either resident's chart regarding the incident, nor were there any behavior notes or incident reports completed. Staff interviews revealed a lack of clarity about the incident and the required documentation, and social services staff were unaware of the event due to the absence of records. The facility administrator acknowledged the lack of documentation and incident reports for these events. Additionally, a resident identified as an elopement risk was observed by staff and family to have left the building on at least two occasions, but there was no documentation of these elopements in the resident's medical record or any incident reports. Staff interviews indicated that management instructed them not to document the incident in the electronic medical record. Another resident with complex wound care needs had multiple gaps in documentation for wound treatments, repositioning, and use of protective devices, as well as oral suctioning. Nursing management confirmed that all such care should be documented, and if it was not, it was considered not done.