Incomplete Clinical Record at Admission
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 maintain complete and accurate clinical records for one resident during the admissions process. Facility policy required that all possible information about a resident be obtained at admission to support care planning and resident comfort. Documentation showed that the resident arrived from the hospital for skilled and rehabilitation services, was signed in by staff, and then left the facility with her husband shortly after arrival. However, there was no documentation in the clinical record to indicate that staff obtained any identifying or admission information about the resident. The Director of Nursing confirmed that the clinical record lacked all required admission information for this resident.