Failure to Maintain Complete and Accurate Medical Record Following Abuse Allegation
Penalty
Summary
The facility failed to maintain a complete and accurate medical record for a resident with multiple diagnoses, including psychosis, severe dementia, and mood disorder. The resident was admitted with significant cognitive and behavioral issues and resided on a secured unit due to safety concerns. Despite an incident in which the resident alleged physical abuse by another resident, there was no documentation in the clinical record regarding the altercation, the abuse allegation, or communication with the resident's guardian about the incident and its investigation. The care plan and progress notes did not reflect the reported event or the guardian's concerns. A review of the facility's self-reported incident and interviews confirmed that an investigation was conducted, but the results and related communications were not documented in the resident's medical record. The guardian made multiple requests for updates regarding the investigation, but only received unrelated information about the resident's personal items. Interviews with facility staff and the guardian verified that the medical record was incomplete and did not accurately reflect the events or follow-up related to the abuse allegation.