Incomplete and Inaccurate Medical Record Documentation
Penalty
Summary
The facility failed to maintain complete and accurate medical records for three residents, resulting in deficiencies related to documentation and safeguarding of resident-identifiable information. For one resident with multiple psychiatric diagnoses, the medical record did not contain documentation that the resident was informed in advance about the risks, benefits, and alternatives for certain prescribed medications, specifically Benztropine Mesylate and Bupropion, prior to administration. Although the facility had obtained consent for other antipsychotic medications, there was no evidence of consent for these two medications in the resident's record. Another resident, admitted following elective spinal surgery, had discharge documentation that included a summary of their stay. However, the nursing summary was found to be a direct copy-and-paste from a physician order regarding the reason for admission, rather than a true summary of the resident's stay at the facility. The nurse manager confirmed this practice, stating it was standard procedure to copy the admission order into the discharge summary, rather than providing an individualized account of the resident's progress and care during their stay. A third resident, who was cognitively intact and admitted with quadriplegia, was transferred to the hospital following a change in condition. The medical record lacked documentation that pertinent information about the resident's condition was communicated to the receiving hospital, and there was no record that the resident was informed about the facility's bed hold policy. Additionally, the required Interact transfer form was not completed or entered into the medical record for this transfer event. A late entry was made in the progress notes to indicate the hospital was notified, but it still did not include information regarding the bed hold policy.