Incomplete Clinical Records for Wound Consultant Visits
Penalty
Summary
The facility failed to maintain complete and accurate clinical records for three of eleven sampled residents. For one resident with iron deficiency anemia, muscle wasting, and osteomyelitis, there was no evidence in the clinical record that the resident was seen by the wound consultant on two specified dates, despite the Administrator stating these assessments should have been scanned into the record. Another resident with Parkinson's disease also lacked documentation of wound consultant visits on the same dates, as confirmed by the Administrator. A third resident with hypertension was similarly missing documentation of a wound consultant assessment on a specified date. These omissions were identified through clinical record review and staff interviews.