Incomplete Medical Record Documentation for Deceased and Wound Care Residents
Penalty
Summary
The facility failed to maintain accurate and complete documentation in the medical records of four out of twelve residents reviewed. Specifically, for one resident who passed away, the clinical record did not include required details such as the date and time of death, the name and title of the individual pronouncing death, and the name of the person removing the deceased from the facility, as mandated by facility policy. The Director of Nursing confirmed these omissions during an interview. Additionally, three other residents with complex medical conditions, including brain cancer, stroke, diabetes, pressure ulcers, and amputations, had incomplete documentation of wound treatments and other ordered care. Multiple entries in their treatment administration records were left blank, indicating that the completion of prescribed treatments was not consistently recorded. The Director of Nursing also confirmed these gaps in documentation, which were contrary to the facility's policies requiring timely and accurate recording of all treatments and care provided.