Incomplete and Inaccurate Medical Record Documentation
Penalty
Summary
The facility failed to maintain complete and accurate medical records for two residents. For one resident, the electronic medical record did not contain a completed discharge summary at the time of discharge. The discharge summary was found to have errors and was not marked as complete or locked in the system, with missing answers to required prompts. Interviews with staff confirmed that the summary was not finalized according to facility expectations, which require a completed, signed, and dated document without errors. For another resident, documentation of showers or baths was inconsistent and not appropriately recorded in the electronic medical record. Initially, only one shower was documented for a specific week, but later, an additional entry was added after staff were prompted to update their documentation. The CNA responsible stated that the shower had been provided but was not documented at the time, and the entry was made later to keep records up to date. The facility's policy requires that a medical record be maintained for every resident in accordance with accepted professional standards, including accurate records of care and services provided.