Failure to Maintain Complete and Accurate Medical Records for Resident with Complex Medical Needs
Penalty
Summary
The facility failed to maintain a complete and accurate medical record for one resident who was admitted following a right leg trimalleolar fracture repair and had multiple complex diagnoses, including chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF), chronic kidney disease (CKD), and acute kidney failure. Documentation reviews revealed that required daily assessments and vital signs were not consistently recorded during the resident's Medicare skilled stay. Specifically, there were gaps in documentation regarding the resident's edema, neurovascular status of the right foot, and the presence or condition of the cast or splint, despite orders for regular monitoring and the resident's high-risk medical profile. Progress notes and assessments frequently omitted critical information such as edema, neurovascular checks, and respiratory status, even though the resident experienced significant weight gain and changes in condition. The medical provider was not notified of the resident's weight gain, and there was no evidence of daily skilled documentation as required by facility policy and professional standards. The facility's own policy required daily documentation for Medicare skilled residents, including full assessments and vital signs, which was confirmed by staff interviews as not being met in this case. Interviews with nursing staff, the Resident Care Manager, the Provisional Administrator, and the Director of Nursing confirmed the lack of required documentation and assessments. The absence of daily monitoring and communication with the medical provider regarding significant changes in the resident's condition, such as weight gain and edema, contributed to the incomplete and inaccurate medical record. The deficiency was substantiated by both record review and staff interviews.