Failure to Maintain Accurate Clinical Documentation
Penalty
No penalty information released
The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.
Summary
The facility failed to ensure that the clinical record for one resident contained accurate and complete documentation. Specifically, after an incident, there was no evidence in the resident's clinical record of a progress note, consult, medication review, or visit summary. Although the facility provided electronic communication from a nurse practitioner indicating the resident was seen for a wellness check, an LPN confirmed that the resident had not been seen by a psychiatrist on the date in question and that no corresponding progress notes were present in the electronic medical record. This lack of accurate documentation was confirmed during interviews with facility staff and reviewed during the exit conference.