Inaccurate Medical Record Entry for Absent Resident
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
Facility staff failed to maintain an accurate medical record for one resident who had been transferred to the hospital for suicidal ideation. During a review of the resident's records, a progress note was found documenting a telehealth visit on a date when the resident was not present in the facility. The unit manager was unable to explain why this note was entered, and the medical record director confirmed that the note did not include any indication of being a late entry or written in error, as required by facility policy. The Director of Nursing also confirmed that the resident was not in the facility on the date the telehealth visit was documented.