Failure to Maintain Accurate Medical Records for Fall Interventions and Bathing Methods
Penalty
Summary
The facility failed to maintain accurate and complete medical records for two residents, specifically regarding fall intervention orders and documentation of bathing methods. For one resident, a fall mat was observed in use without a corresponding physician order in the medical record; staff confirmed the mat was regularly in place, and a registered nurse acknowledged the absence of an order at the time of observation. For another resident, the medical record lacked documentation specifying the method of bathing provided, and the Director of Nursing confirmed that there was no way to verify whether the resident received a shower, bath, or bed bath other than by asking the resident or the nurse aide. These deficiencies were identified through observation, staff interviews, and record review.