Incomplete Medical Record Documentation for Deceased Resident
Penalty
No penalty information released
The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.
Summary
The facility failed to ensure that medical records for each resident were complete and accurately documented, as required. Specifically, for one resident with diagnoses including malignant neoplasm of the kidney, major depressive disorder, and hypertension, the clinical record review showed that the resident ceased to breathe on a specified date and time. However, there was no nurse progress note documented for the date when the resident ceased to breathe. This omission was confirmed by the Director of Nursing during an interview, acknowledging that the medical record was incomplete and not accurately documented for this resident.