Incomplete and Inaccurate Medical Record Documentation
Penalty
Summary
The facility failed to ensure that medical records were complete and accurate for three residents. For one resident with multiple fractures, Alzheimer's disease, and severe cognitive impairment, the Social Services Social History Assessment was left blank and marked as 'in progress' after admission. This assessment, which should have been completed within the first week, included essential questions about the resident's background, support system, discharge planning, and medical needs. The current Social Services Coordinator confirmed the assessment was not completed and could not provide a reason for the omission. Another resident with bipolar disorder, muscle weakness, and spinal conditions had inconsistencies in shower documentation. The electronic record indicated showers were provided during night shifts, but interviews with CNAs revealed that showers were only given during the second shift and that some entries were documented under the wrong area or entered late. This resulted in inaccurate records regarding the resident's care activities. A third resident with a history of cerebral infarction and mobility issues also had discrepancies in shower documentation. The records showed multiple showers on the same day and conflicting levels of assistance required, which staff confirmed did not reflect actual care provided. Staff interviews revealed confusion about documentation procedures, with some showers not properly recorded or corresponding between electronic records and shower sheets. The facility's policy required accurate documentation of these services, which was not followed.