Incomplete and Inaccurate Clinical Record Documentation
Penalty
Summary
The facility failed to ensure that clinical records for multiple residents were complete and accurately documented, as required by accepted professional standards. Specifically, for six out of eight residents reviewed, there were missing or incomplete entries in the shower records for various dates. In several instances, documentation was left blank or marked as 'NA,' which was confirmed by the Director of Nursing to be unacceptable. These documentation lapses were identified through clinical record reviews and staff interviews. The residents affected included individuals with cognitive impairments and those requiring moderate to total assistance with personal care, such as showering. The deficiencies were noted across both cognitively impaired and intact residents, with some having significant medical conditions like diabetes mellitus. The lack of proper documentation was observed over multiple months and for multiple residents, indicating a pattern of incomplete record-keeping for essential care activities.