Failure to Maintain Complete and Accurate Medical Records for a Resident
Penalty
Summary
The facility failed to maintain complete and accurate medical records in accordance with accepted professional standards for one resident. A complaint was received alleging that the resident was often not fed due to short staffing, and that the resident's spouse had to visit to ensure the resident was fed. The resident had multiple diagnoses, including systemic lupus erythematosus, chronic pain, heart failure, muscle wasting, and a cognitive communication deficit. A review of the resident's medical record revealed significant gaps in the documentation of meal consumption by geriatric nursing assistants (GNAs). Specifically, there were multiple days across April, May, and June where documentation for breakfast, lunch, and/or dinner was missing. The missing records included both partial and full days without any entries, making it impossible to validate the amount of food the resident consumed. Facility leadership reviewed and agreed with the findings that the documentation was incomplete.