Incomplete and Inaccurate Medical Record for Resident
Penalty
No penalty information released
The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.
Summary
The facility failed to maintain a complete and accurate medical record for a resident who was reviewed for this requirement. The resident's face sheet indicated admission in April, and a vital sign record from May did not include any entries after the resident returned from an elopement. A paper document dated in May listed the resident's first name only, along with vital signs recorded without a time, and did not include this information in the electronic medical record. During an interview, the DON was unable to locate the vital signs in the electronic record and found them only on an old nurse assignment sheet. The facility's policy requires all paper records to be stored securely in locked areas.