Failure to Document Resident Incidents in Medical Records
Penalty
Summary
The facility failed to maintain accurate and complete medical records for two residents, as required by accepted professional standards. For one resident, who had a history of depression and dementia but demonstrated little to no cognitive impairment, an incident occurred in which the resident alleged that a staff member called her 'evil' during an activity. Although the incident was reported to the state, investigated, and statements were collected from staff and other residents, there was no documentation of the incident in the resident's medical chart. Both the Director of Nursing (DON) and the Administrator confirmed that this incident should have been documented by nursing staff, as it pertained to the resident's care and behavior needs. In a separate case, another resident with moderate cognitive impairment and a diagnosis of metabolic encephalopathy versus TIA reported that $40 was stolen from his wallet while he was napping. The incident was reported to the state, the resident's room and wallet were searched with his permission, and the family and local police were notified. Despite these actions, there was no documentation of the incident in the resident's medical record. Interviews with the Assistant Director of Nursing (ADON), a Licensed Vocational Nurse (LVN), the DON, and the Administrator all confirmed that the incident was not documented as required. The facility's own documentation guidelines require that all individuals who document in the medical record follow good clinical record practice. The lack of documentation for these incidents was acknowledged by facility leadership, who stated that nurses are responsible for documenting such events to ensure continuity of care. The omission of these records could result in inaccurate resident records and impact the provision of needed services due to documentation errors.