Inaccurate Medical Record Documentation for Cognitively Impaired Resident
Penalty
Summary
The facility failed to maintain a complete and accurate medical record for one resident with severe cognitive impairment and multiple diagnoses, including vascular dementia and complications from a stroke. The resident's care plan inaccurately listed a nickname that was not used by the resident, and the Durable Power of Attorney (DPOA) confirmed that using this nickname would cause confusion. The DPOA also stated that the resident could not participate in traditional leisure activities and had not attended any outings, which would have required her permission. Multiple staff interviews corroborated that the resident did not participate in group activities due to cognitive deficits. Despite this, the activity attendance record documented the resident as having participated in various group activities and outings, including after the resident had already been discharged to an acute care setting. The Activity Director acknowledged that some activities recorded, such as self-propelling a wheelchair or looking out a window, did not meet the definition of leisure activities and confirmed that outings were not offered by the facility. The Activity Director also noted that the activity assistant responsible for documentation had difficulty accurately recording attendance, likely resulting in erroneous entries. These inaccuracies resulted in a medical record that was not factual, accurate, complete, or current.