Failure to Maintain Accurate Medical Records and Discharge Documentation
Penalty
Summary
The facility failed to maintain clear and accurate medical records for two residents, resulting in incomplete documentation of behaviors, care needs, and discharge processes. For one resident with a history of borderline intellectual functioning, bipolar disorder, and anxiety, there was no documentation in the medical record regarding a reported yelling incident and ongoing behavioral issues, despite staff interviews indicating repeated behavioral concerns and a care plan that included monitoring for such behaviors. Multiple staff members were either unaware of the need to monitor this resident or reported no behaviors observed, and behavior monitoring reports did not reflect the incidents described by staff. For another resident with dementia and behavioral disturbances, the medical record did not accurately document wandering behaviors, exit-seeking, or the resident's inability to locate his room, even though several staff and family interviews confirmed these behaviors were frequent and escalating prior to discharge. The care plan and behavior monitoring reports failed to include or reflect these significant behaviors, and documentation of wandering was notably absent despite it being an available option in the monitoring system. Additionally, when this resident was discharged due to increased behavioral needs that could not be met at the facility, there was no written notification of discharge provided to the resident's representative, and this documentation was not uploaded into the medical record as required by facility policy. The provider discharge summary also lacked specific details about the behaviors leading to discharge and the rationale for transfer, further contributing to the incomplete and inaccurate medical record.