Failure to Maintain Complete and Accurate Medical Record Following Resident Allegation
Penalty
Summary
The facility failed to maintain a complete and accurate medical record for a resident with late onset Alzheimer's Disease, anxiety, and generalized muscle weakness, who was severely cognitively impaired. The resident reported to the Social Services Director (SSD) that a night aide had pushed her against the wall, and this was noted during a psychosocial assessment. Although a 5-Day Investigation documented the incident, including notifications to the Nursing Home Administrator (NHA), Director of Nursing (DON), local authorities, health care provider, and the resident's guardian, there was no corresponding documentation in the resident's electronic medical record (EMR) or progress notes regarding the allegation, the notifications, or the reason for the skin assessment performed on the same day. Further review of the resident's progress notes and EMR revealed no mention of the reported incident, the notifications made, or the context for the follow-up interactions with the resident. Interviews with facility staff, including the SSD, RN, and NHA, confirmed that such incidents and notifications should have been documented in the resident's medical record. The lack of documentation regarding the incident, the notifications, and the rationale for assessments resulted in an incomplete and inaccurate medical record for the resident.