Incomplete and Inaccurate Medical Record Documentation
Penalty
Summary
The facility failed to maintain complete and accurate medical records for a resident with a history of stroke, aphasia, and heart disease, who was admitted with severely impaired cognition. A progress note in the resident's clinical record, dated 7/19/25 and attributed to a social services staff member, stated that the resident had been deemed incompetent by a court and had a public legal guardian. However, upon review, there were no guardianship documents in the record, and both the social services staff member and the administrator confirmed that the resident did not have a guardian. The family member was in the process of obtaining Power of Attorney, as advised by a lawyer, due to the resident's aphasia and cognitive impairment. Further investigation revealed that the social services staff member whose name was on the progress note denied writing it and stated she did not share her computer with anyone else. The administrator was unable to determine who authored the note, despite it being electronically signed by the staff member. The facility's policy requires that medical records be complete, accurately documented, and systematically organized, but this incident demonstrated a failure to ensure the accuracy and integrity of the resident's medical record.