Incomplete and Inaccurate Medical Record Documentation for Resident
Penalty
Summary
The facility failed to ensure that clinical and medical records were complete and accurate for one resident. Review of the resident's face sheet and Minimum Data Set indicated admission and a completed death assessment, but there was no documentation in the nursing progress notes or electronic health record regarding the resident's clinical status or condition on the relevant date. Vital signs, including blood pressure, heart rate, and breathing rate, were last documented prior to the date in question, and there was no record of these measurements on the day the resident left the facility for a planned diagnostic procedure. Interviews with the LPN assigned to the resident and the Director of Nursing confirmed the absence of documentation regarding the resident's clinical status, the planned medical appointment, or the resident's departure from the facility. The Director of Nursing acknowledged that there was no documentation about the resident's clinical status or death in the medical record, and that such documentation was expected. The lack of documentation resulted in incomplete and inaccurate medical records for the resident.