Incomplete and Inaccurate Medical Record Documentation
Penalty
Summary
The facility failed to maintain complete and accurate medical records for three residents, resulting in missing documentation of care and significant events. For one resident with a history of refusing care, staff did not document repeated attempts to change briefs, provide showers, put sheets on the bed, or change the mattress, despite the resident's noncompliance and the presence of strong urine odor in the room. Interviews with the ADON confirmed that these care attempts and refusals were not consistently recorded in the medical record. Another resident experienced a fall due to weakness and imbalance, but staff did not document the fall, any post-fall assessment, or notifications to the provider or family. The DON confirmed that the expected documentation for such incidents, including assessment and notifications, was missing from the resident's medical record. A third resident did not receive prescribed medications on two occasions because the medications were unavailable. Although staff noted the unavailability in the medication administration record, there was no documentation in the progress notes that the physician was notified about the missed doses. The DON confirmed that staff are expected to notify the provider when medications are not available, but this was not documented.