Incomplete and Inaccurate Medical Record Documentation for Two Residents
Penalty
Summary
The facility failed to maintain complete and accurate medical records for two residents, resulting in deficiencies in clinical documentation. For one resident, the admission record, care plan, and Minimum Data Set (MDS) did not include any medical diagnoses, despite the presence of multiple medication orders that referenced specific conditions such as COPD, hypertension, and anxiety. Hospital discharge records for this resident listed several diagnoses, but these were not reflected in the facility's electronic health record or care planning documents. The MDS nurse confirmed that diagnoses should be added during the admissions process and that the MDS had not yet been completed for this resident. For another resident, the facility did not accurately document a significant skin issue. After the resident sustained a laceration to the forehead requiring staples, the weekly skin assessment completed three days later indicated no new skin issues and did not mention the presence of staples or the wound. The medication administration record did include an order to monitor the laceration and staples, but this was not reflected in the skin assessment documentation. The DON stated that her expectation was for skin assessments to be completed accurately and for diagnoses to be present in every medical record upon admission.