Incomplete and Inaccurate Medical Records for Two Residents
Penalty
Summary
The facility failed to maintain complete and accurate medical records for two residents. For one resident, a physician's order for Trazodone 50 mg daily for depression was present in the medical record, but the corresponding diagnosis of depression was not listed among the resident's active diagnoses. This discrepancy was confirmed by the Registered Nurse Unit Manager, who acknowledged the absence of the depression diagnosis in the record. For another resident, a physician's order for a dysphagia advanced diet was found, and a Speech and Language Pathologist evaluation documented a diagnosis of dysphagia, oral phase. However, the active diagnoses in the resident's medical record did not include dysphagia, a fact acknowledged by the Director of Nursing during review.