Incorrect Medical Record Uploads Compromise Documentation Accuracy
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 ensure accurate clinical documentation by erroneously uploading documents belonging to two other residents into the electronic health record (EHR) of a third resident. Specifically, a POLST (Physician Orders for Life-Sustaining Treatment) form for one resident and a medication clarification notice for another were found in the medical record of a different resident. This error was identified during a clinical record review and confirmed through staff interviews. The Nursing Home Administrator and Director of Nursing were notified of these findings, which demonstrated that the facility did not maintain accurate and resident-specific clinical records as required.