Incomplete and Disorganized Medical Record Documentation
Penalty
Summary
The facility failed to maintain complete, accurate, and systematically organized medical records for two residents. For one resident with a history of depression and anxiety, the electronic chart contained two Preadmission Screening and Resident Reviews (PASSR). The second PASSR indicated an evaluation was required for a significant change, but there was no documentation of such an evaluation in the resident's chart or in the progress notes. Staff interviews revealed uncertainty about the follow-up on the PASSR, and no notes were found regarding the required evaluation. For another resident admitted with hospice enrollment, the care plan documentation was incomplete. The care plan conference note indicated only social services attended, and key elements such as disease diagnosis, health and skin conditions, special treatments, medication reconciliation, and various care plans were left blank. There was also no documentation regarding hospice care services. Staff interviews confirmed that the care conference documentation was not completed in a timely manner, with the responsible staff still working on it ten days after the conference.