Failure to Maintain Comprehensive and Timely Medical Records
Penalty
Summary
The facility failed to ensure that progress notes and medical records for multiple residents were comprehensive, accurate, and maintained in chronological order, as required by accepted professional standards. For one resident with complex medical needs, including pressure ulcers and opioid dependence, there were no status updates or discharge documentation after a hospital transfer, and attempts to contact the resident's spouse were not recorded. The admissions director confirmed that tracking and documentation protocols were not followed, especially when the resident was transferred to an out-of-network hospital. Another resident with psychiatric and mobility diagnoses had progress notes that were incomplete and inaccurate. Nursing staff documented a leave of absence but failed to clearly identify which parties were notified, and subsequent notes referenced the wrong date of the event. In a separate case, a resident with impaired cognition and multiple mental health diagnoses experienced a witnessed staff-to-resident verbal abuse incident, but there was no documentation in the progress notes regarding the incident, the investigation, or notifications to the physician, family, or police. Additional deficiencies included multiple late entry notes for a resident with severe malnutrition and cognitive deficits, with staff acknowledging that documentation was not completed timely due to workload. Another resident's record showed a lack of documentation regarding the rationale for a urinalysis order, family notification, and late entries for antibiotic use, with staff confirming that behaviors and notifications were not recorded. The facility's own policy requires timely, accurate, and complete documentation, but these standards were not met in the reviewed cases.