Incomplete and Inaccurate Medical Record Documentation
Penalty
Summary
The facility failed to maintain complete and accurate medical records for three out of 32 sampled residents, resulting in discrepancies and omissions in resident documentation. For one resident with heart failure, hypertension, and stroke, the electronic medical record (EMR) included progress notes describing a significant change in condition and subsequent transfer to the hospital, but the Notice of Emergency Transfer listed only 'General Weakness' as the reason for transfer, lacking specific clinical details. Another resident with bilateral above-the-knee amputation was transferred to the hospital for unrelieved pain, but the admission Minimum Data Set (MDS) was not completed prior to transfer, and the transfer documentation inconsistently listed the reason for transfer as 'Evaluation' rather than the specific clinical issue. Interviews with facility staff revealed that transfer paperwork was sometimes completed retrospectively and that staff misunderstood the requirement to document the specific reason for transfer. Additionally, a resident with an unstageable pressure ulcer of the sacral region had no documentation of the wound on the admission MDS, despite nursing progress notes indicating the presence of a pressure sore. An LPN acknowledged that the wound's appearance should have been documented, and the Director of Nursing confirmed that wound descriptions are required. Facility policies reviewed indicated that transfer/discharge notices must include the specific reason for transfer and that skin assessments should describe wounds, but these requirements were not consistently followed.