Incomplete and Disorganized Medical Records for Two Residents
Penalty
Summary
The facility failed to maintain complete, accurate, and systematically organized medical records for two residents. For one resident with severe vascular dementia, hypertension, and depression, the medical record did not contain an updated Pre-admission Screening/Resident Review (PASRR) reflecting a new diagnosis of depression, despite multiple psychiatric and nursing notes indicating the presence of depression and the initiation of antidepressant therapy. Interviews with staff confirmed that the PASRR was not updated in the medical chart when the new diagnosis was made, and the updated PASRR was not initially available in the resident's record. For another resident with a history of atherosclerotic heart disease, hypertension, diabetes, bipolar disorder, and muscle weakness, there was no documentation in the medical record regarding an elopement event that had been reported by the facility. The Regional Nurse Consultant confirmed that any change of condition, such as an elopement, should be documented in the progress notes, but no such documentation was found in the resident's file.