Failure to Maintain Complete and Accurate Medical Records
Penalty
Summary
The facility failed to maintain complete and accurate medical records for two residents, as required by professional standards. For one resident with multiple sclerosis and a stage IV sacral pressure ulcer receiving hospice care, review of the Treatment Administration Records (TARs) for August, September, and October revealed that staff did not sign off on wound treatments on several specific dates. The wound nurse confirmed in an interview that the dressings were completed on those days but she forgot to document them in the TARs. The Director of Nursing also confirmed the lack of accurate documentation for the wound treatments on the identified dates. For another resident admitted with multiple chronic conditions, including bilateral lower extremity wounds, lymphedema, and severe chronic kidney disease, the medical record review showed incomplete wound documentation. There were missing wound assessment notes for over a month, and the TAR for wound care was left blank on several days, making it unclear if treatments were performed. Additionally, weekly skin sheets lacked measurements for multiple weeks, resulting in an incomplete medical record related to the resident's wounds.