Incomplete and Inaccurate Medical Records for Secure Unit Placement
Penalty
Summary
The facility failed to ensure that medical records were complete and accurately documented for two residents regarding their admission orders and secure unit placement. For the first resident, there were no active orders reflecting admission to the facility or to the secure unit at the time of review. The resident's elopement risk evaluation was not completed or available in the electronic medical record until after the investigation began, and the order for secure unit placement was only entered after the investigation was underway. Interviews with facility staff, including the DON and ADON, confirmed that there was no active admission order and that the move to the secure unit was not properly documented in the resident's orders, despite being care planned. For the second resident, a similar deficiency was identified. The resident's order summary and recap reports showed no active orders for facility admission or secure unit placement at the time of review. Previous orders for admission and secure unit placement had been discontinued without documented reasons, and late entries were made for prior skilled services. The care plan indicated that the resident was to reside in the memory care unit due to dementia and elopement risk, but this was not supported by current, active physician orders in the medical record. Both residents had significant medical histories, including dementia, heart failure, and psychiatric diagnoses, and were assessed as having varying levels of elopement risk. Despite these risks and the need for secure unit placement, the facility did not maintain complete and accurate physician orders in accordance with accepted professional standards. The facility's own policy required that physician orders be complete, accurate, and maintained in the resident's medical record, but this was not followed for these two residents.