Incomplete and Inaccurate Medical Records for Diabetic Resident
Penalty
Summary
The facility failed to maintain complete and accurate medical records for one resident, specifically omitting a diabetes diagnosis from the resident's face sheet, care plan, and other key documentation, despite the resident receiving diabetic medications and insulin. Record reviews showed that the resident's face sheet, care plan, and Minimum Data Set (MDS) assessment did not list diabetes as a diagnosis, even though physician orders and the Medication Administration Record (MAR) documented the administration of insulin and metformin for diabetes. The care plan also lacked any interventions or goals related to diabetes management. Interviews with facility staff revealed a lack of awareness and accountability regarding the accuracy of resident records. The Admissions Director was responsible for completing face sheets, while the Regional MDS Coordinator was responsible for care plans. The MDS Coordinator stated he was unaware of the inaccuracies and believed the Interdisciplinary Team (IDT) was responsible for ensuring records were accurate and complete. The Director of Nursing (DON) acknowledged that missing diagnoses could result in improper or inadequate care but was unsure how the omission occurred. The Administrator indicated that the clinical leadership team and hospice provider were responsible for ensuring accurate information in the records but was unable to explain why the diabetes diagnosis was missing. Additionally, when asked for the facility's medical record policy, the Administrator stated that no such policy was available. The lack of accurate documentation for the resident's diabetes diagnosis was identified through record review and staff interviews.