Failure to Maintain Complete and Accurate Medical Records
Penalty
Summary
The facility failed to maintain complete, accurate, and systematically organized medical records for multiple residents, as required by facility policy and professional standards. For one resident with Alzheimer's disease, seizures, and intellectual disabilities, there was no documentation in the medical record regarding a significant change in condition and subsequent death. Although staff interviews confirmed that the resident experienced a decline, was assessed by nursing staff, and emergency services were called, none of these events or the resident's passing were recorded in the medical record. Another resident who expressed suicidal ideations did not have appropriate nursing documentation following the incident. While progress notes indicated the resident made statements about self-harm and staff redirected her, there was no evidence of follow-up or nursing assessment documented in the medical record, despite facility policy requiring such documentation for suicide threats. Interviews with facility leadership confirmed that nursing documentation was expected in these circumstances. Additionally, the facility failed to document a resident-to-resident altercation in both involved residents' medical records. While one resident's progress notes described the altercation and staff intervention, the other resident's record contained no documentation of the incident, contrary to facility policy requiring incident documentation for all involved parties. These omissions resulted in incomplete medical records that did not accurately reflect the care provided or the residents' conditions.