Failure to Maintain Accurate and Complete Medical Records
Penalty
Summary
The facility failed to maintain accurate and up-to-date medical records for multiple residents, resulting in discrepancies regarding code status, wound care documentation, and charting after discharge. For one resident with diagnoses including acute respiratory failure and COPD, the medical record contained conflicting information about code status. While the physician order and care plan indicated full code status, the resident had transitioned to hospice care with a DNRCC order, which was not promptly or clearly reflected in the records. The Director of Nursing was unable to confirm the resident's current code status during the interview, and the updated DNRCC documentation was only later found uploaded in the record. Another resident, who had been admitted with chronic conditions and later discharged after a hospital transfer, had progress notes entered by nursing staff documenting vital signs and health status on days after the resident had already left the facility. The DON confirmed that these entries were inaccurate, as the resident was not present in the facility at the time the notes were made. A third resident with multiple chronic conditions and pressure ulcers was seen by an outside wound nurse practitioner, but the assessment and treatment recommendations from that visit were never received or uploaded into the resident's medical record. The Assistant DON verified that the documentation should have been included to ensure the record was complete and accurate. These failures affected three of the ten residents reviewed for accurate medical record information.