Failure to Maintain Complete and Accurate Clinical Records
Penalty
Summary
Facility staff failed to maintain a complete and accurate clinical record for two residents. For one resident with a history of stroke and severe cognitive impairment, the facility's shower schedule and shower sheets indicated that showers were provided every Monday and Thursday. However, the activities of daily living (ADL) tracking sheets did not document that these showers occurred as scheduled. The director of clinical services confirmed that the shower sheets were kept in a separate binder and were not considered part of the clinical record, resulting in incomplete and inaccurate documentation for this resident. In a separate incident, staff failed to document in the clinical record an event where one resident touched another resident's breast. Although the incident was reported to the state agency and staff intervened immediately, there was no documentation of the event in the affected resident's clinical record. The director of clinical services acknowledged that this incident should have been documented. Both deficiencies were confirmed by administrative staff during interviews.