Failure to Maintain Accurate and Timely Medical Records for Significant Resident Events
Penalty
Summary
The facility failed to maintain accurate and timely medical records for two residents, resulting in incomplete documentation of significant events. For one resident with multiple chronic conditions, including congestive heart failure, diabetes, and dementia, there was no documentation of a fall that occurred in her room until three days after the incident, when her daughter presented video evidence to the DON. The nurse did not document the fall, complete an incident report, or implement immediate interventions, leaving the resident's medical record incomplete and inaccurate. In another case, a resident with a history of pulmonary embolism, pleural effusion, and chronic pain left the facility in a wheelchair and was found in the middle of a street. Police and facility administration were involved in returning the resident to the facility. Despite the seriousness of the event, the medical record did not include any documentation of the resident being in the street, the involvement of law enforcement, or the efforts made by staff and administration to return the resident to the facility. Interviews with the DON confirmed that in both cases, the medical records did not accurately reflect the events that occurred, nor did they include timely or complete documentation as required by facility policy. The lack of documentation failed to provide a truthful and current account of the residents' status and the care provided during these incidents.