Incomplete and Inaccurate Medical Records for Resident Diagnoses
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 ensure that medical records were complete and accurate for one of three residents reviewed for unnecessary medications. Specifically, a resident was admitted with diagnoses including unspecified dementia and insomnia. However, a provider's progress note later documented a diagnosis of moderate dementia with anxiety, which was not added to the resident's official list of diagnoses. During an interview, the DON confirmed that staff are expected to update the diagnoses list when a new diagnosis is identified, but this was not done in this case.