Failure to Accurately Update Resident Medical Record with New Diagnosis
Penalty
Summary
The facility failed to maintain complete and accurate medical records for one resident, as required by accepted professional standards. Specifically, a psychiatric physician added a diagnosis of general anxiety and prescribed diazepam 2 mg three times daily for anxiety, but this new diagnosis was not added to the resident's medical record. The resident's face sheet and electronic medical record did not reflect the updated diagnosis, despite the medication being ordered and administered for anxiety. The resident's medication administration record and physician orders confirmed the ongoing use of diazepam for anxiety, and the psychiatric physician's note documented the addition of the diagnosis. The Director of Nursing confirmed that the resident was receiving diazepam for anxiety and that the psychiatric doctor had added the diagnosis of general anxiety, but acknowledged that the facility did not update the medical record accordingly. It was noted that updating the medical record was the responsibility of the MDS nurse, but the facility did not have an MDS nurse at the time, which contributed to the inaccuracy. The facility's policy allowed for the use of electronic medical records, but the failure to update the diagnosis resulted in an incomplete and inaccurate medical record for the resident.