Incomplete and Inaccurate Clinical Records for Resident Diagnoses
Penalty
Summary
The facility failed to maintain complete and accurate clinical records for one resident, as required by accepted professional standards. Specifically, the resident's face sheet and clinical record did not include all current diagnoses, omitting both Hypertension and Hypothyroidism, despite the presence of physician orders for medications to treat these conditions. The omission was confirmed during an interview with the Director of Nursing, who acknowledged that the face sheet, which is used by outside health providers, should accurately reflect the resident's health status. Record review showed that the resident was admitted with diagnoses of Heart Failure, Pneumonia, and Muscle Wasting and Atrophy, but the additional diagnoses of Hypertension and Hypothyroidism were not documented in the resident's list of diagnoses or on the face sheet. The resident's admission MDS assessment and comprehensive care plan were still in process and not yet due for completion, and therefore did not yet include all diagnoses. The facility's policy requires that each resident's medical record contain an accurate representation of the resident's experiences and enough information to provide a complete picture of the resident's progress.