Failure to Update Medical Records Following Change in Resident Status
Penalty
Summary
The facility failed to maintain accurate and up-to-date medical records for two residents who were no longer residing in the secured unit. Both residents had diagnoses including dementia and other cognitive impairments, and their care plans and physician orders continued to indicate that they resided in the secured unit, despite both having been moved to the general population. Observations confirmed that both residents were located outside the secured unit, and interviews with staff and family members corroborated that the residents' locations and care needs had changed. However, the medical records, including care plans and physician orders, were not updated to reflect this change. The Director of Nursing (DON) acknowledged that verbal orders had been given to move the residents out of the secured unit, but these changes were not documented in the residents' records. The Corporate RN also confirmed that the records were inaccurate and should have been updated when the residents were moved. The facility's own policy requires that each resident's medical record accurately represent their current status and care needs, but this was not followed in these cases.