Failure to Maintain Complete and Accurate Medical Records
Penalty
Summary
The facility failed to maintain complete and accurate medical records for three residents, as required by professional standards and facility policy. For one resident with a history of cirrhosis and ascites, who was admitted with an indwelling urinary catheter, there was no documented order for catheter care in the medical record, despite the care plan and nursing documentation indicating that catheter care was being provided every shift. Interviews with nursing staff and administration revealed that orders for catheter care should have been entered upon admission, but there was no evidence that this occurred. Another resident, admitted with hemiplegia and muscle wasting, required substantial assistance with activities of daily living (ADLs), including showering and personal hygiene. Documentation for scheduled showers was missing for two specific dates, and staff interviews confirmed that care such as showers and ADLs should be documented in the electronic record, including refusals or if the resident was not present. The interim DON and Regional Director of Operations both stated that they expected staff to document all care provided in the resident's medical record. A third resident, with diagnoses including aphagia, dysphagia, and vascular dementia, was dependent on staff for all ADLs and was noted to be resistive to care. Family concerns were raised regarding missed showers, and the DON was unable to locate shower documentation for two months. The DON confirmed that shower care was documented on paper forms during that period, but these records were missing from the resident's medical record. The interim DON reiterated that such documentation should be included in the resident's record, and the RDO expected all care to be documented.