Failure to Maintain Accurate Behavioral Health Records
Penalty
Summary
The facility failed to maintain accurate and complete medical records for three of five sampled residents, specifically regarding behavioral health assessments and documentation. For one resident with multiple psychiatric diagnoses, there was no evidence in the medical record that behavioral health services were provided as documented by the practitioner, with a gap between the referral and the first documented behavioral health visit. Another resident, also with psychiatric diagnoses and on psychotropic medications, had a behavioral health assessment indicating a follow-up was needed in six weeks, but there was no evidence in the record of any follow-up assessment or documentation of rescheduling for over six months. A third resident with major depressive disorder had a similar lapse, with a behavioral health assessment indicating a follow-up in four to six weeks, but no documentation of follow-up or rescheduling for four months. Staff interviews confirmed that behavioral health assessments were sent electronically and were supposed to be printed and scanned into the residents' medical records, but these records were not available for the residents in question. The lack of timely and accurate documentation of behavioral health assessments and follow-up visits resulted in incomplete medical records for these residents.