Incomplete and Inaccurate Medical Record Documentation
Penalty
Summary
The facility failed to maintain complete and accurate medical records for a resident with a history of cerebral infarction and hemiplegia. Upon review, it was found that the resident's medical record did not include all relevant diagnoses, specifically omitting hemiplegia on the information sheet submitted for nursing home level of care appeal. Instead, the documentation listed a diagnosis of no residual deficit, which did not accurately reflect the resident's condition. Additionally, the documentation provided for the appeal did not include all of the resident's diagnoses, and the information sheet was incomplete. Further review revealed that the facility did not maintain up-to-date records of care plan meetings and discussions regarding the resident's loss of nursing home level of care. There was no evidence in the medical record of a care plan meeting after April, nor documentation of discussions with the resident and their representative about the loss of level of care. Although a care plan meeting was held in July, the documentation was kept in the Social Services Assistant's office and had not been uploaded to the medical record, resulting in incomplete official records.