Incomplete Medical Record Documentation Provided to Surveyor
Penalty
Summary
The facility failed to provide complete and accurate medical record documentation as requested by surveyors for a resident with multiple medical diagnoses, including heart failure, renal insufficiency, diabetes, depression, and chronic obstructive pulmonary disease. The resident was cognitively intact and required varying levels of assistance for daily activities, with frequent incontinence noted. During the survey, the surveyor requested a copy of an appointment record from the receptionist, who was also responsible for scheduling appointments. Instead of providing the original requested document, the receptionist delayed the process and was later found creating a new appointment form to give to the surveyor, rather than copying the existing record. Both the receptionist and a clinical regional registered nurse confirmed that the document was being altered to reflect only the date of the appointment, despite the surveyor's request for the entire original document. This action resulted in the facility not providing the complete information as required.