Deficient Clinical Record Accuracy and Maintenance
Penalty
Summary
The facility failed to ensure the accuracy and proper maintenance of clinical records for several residents, resulting in multiple documentation deficiencies. For one resident, there was a discrepancy between the discharge date listed on the face sheet and the date documented in the nursing progress notes, with staff confirming the face sheet should have matched the progress notes. Another resident's clinical record contained hospice documents that actually belonged to a different resident, and staff acknowledged these documents were incorrectly filed. Additionally, a self-administration of medication evaluation form for another resident was found to be blank and not completed as required after assessment, which staff confirmed should have been done. A further review revealed that a resident's Level I PASARR form did not accurately reflect their diagnoses of depression and anxiety disorder, despite these being listed on the face sheet. Staff involved in the review and interviews confirmed that the PASARR form was incomplete and should have included the resident's mental health diagnoses. These findings demonstrate failures in maintaining accurate, complete, and resident-specific clinical records as required by professional standards.