Failure to Accurately Document Clinical Records and Resident Diagnoses
Penalty
Summary
The facility failed to maintain accurate clinical records in accordance with accepted professional standards and practices for four residents. Specifically, therapy staff did not accurately document the completion of Rehab Joint Mobility Screens (JMS) for three residents. For each of these residents, the JMS was dated for a specific quarter but was actually completed and signed several months later. The documentation did not indicate that these were late entries, nor did it specify how the range of motion (ROM) measurements were obtained after the fact. Both the co-Director of Rehabilitation and the Assistant Director of Nursing confirmed during interviews that the JMS should have been completed on time, and if late, should have been clearly documented as such with an explanation for the delay and the method of assessment. For one resident, the facility also failed to ensure that a diagnosis of anxiety was included in the resident's medical record, despite evidence in the history and physical, care plan, and psychiatric progress notes that the resident was being treated for anxiety with Ativan. The omission of this diagnosis from the resident's official diagnosis list meant that the medical record did not accurately reflect the resident's conditions or the rationale for prescribed medications. Multiple staff, including the Quality Assurance Nurse, MDS Nurse, and Director of Nursing, acknowledged during interviews that the anxiety diagnosis should have been included in the resident's record to ensure accurate documentation and appropriate care planning. The facility's policy and procedure on charting and documentation, last reviewed in January 2025, requires that all services provided to residents and any changes in their medical or mental condition be documented in the medical record. The failure to accurately document the timing and method of JMS assessments, as well as to include all relevant diagnoses, resulted in incomplete and inaccurate medical records for the affected residents.