Failure to Maintain and Provide Complete Medical Records
Penalty
Summary
The facility failed to maintain and make accessible complete medical records for seven residents, as required for thorough investigation and in accordance with accepted professional standards. During the review, it was found that essential documentation such as care plans, progress notes, physician orders, medication administration records (MAR/TAR), CNA care tasks, shower sheets, pressure ulcer and wound assessments, skin assessments, and change of condition assessments were missing for multiple months relevant to the residents' care. This lack of documentation was identified for residents with complex medical histories, including diagnoses such as osteomyelitis, pressure ulcers, fractures, diabetes, chronic respiratory failure, and mental status changes. The deficiency was further highlighted when documentation requests were made for specific time periods and incidents, but the facility was unable to provide the required records. The Director of Nursing and the Administrator stated that documentation prior to the facility's acquisition was unavailable, and only the Minimum Data Set (MDS) and face sheets could be provided. This lack of accessible records included not only resident care documentation but also employee records for staff who had worked during the relevant periods. A review of the facility's policy on medical record retention indicated that records should be maintained in accordance with state and federal laws. However, the facility's inability to produce the necessary documentation for the specified residents and timeframes prevented a thorough investigation into the care provided, as required by regulatory standards.