Incomplete Medical Record Documentation for Dependent Resident
Penalty
Summary
The facility failed to maintain medical records according to accepted professional standards for one resident. Review of the facility's policy indicated that all services provided to a resident, as well as any changes in their medical or mental condition, must be documented in the resident's medical record. Documentation should include care-specific details such as the name and title of the individual providing care, the resident's response to treatment, any refusals, notifications made, and the signature and title of the documenting staff. For one resident with significant medical needs, including anoxic brain injury, contractures, reduced mobility, tracheostomy, and epilepsy, the care plan required two-person assistance for activities of daily living and total dependence on staff for personal and oral hygiene. Despite physician orders for two-person assist for care and bi-weekly bathing with skin evaluations, the electronic treatment administration record (e-TAR) showed incomplete documentation for paired care on several specified dates and incomplete bathing tasks on other dates. These findings were confirmed with the facility's administrator and assistant director of nursing, indicating that the required documentation for care and bathing was not consistently completed as per policy and physician orders.