Failure to Accurately Transcribe and Maintain Resident Diagnoses
Penalty
Summary
The facility failed to accurately transcribe and maintain complete medical records for a resident, specifically omitting a diagnosis of dementia from the resident's records. The resident's face sheet and other clinical documentation did not reflect the dementia diagnosis, despite multiple sources, including hospital records and documentation from the resident's physician, indicating the presence of dementia. The omission was confirmed through interviews with facility staff, including the MDS coordinator and DON, who acknowledged that the diagnosis was not entered into the database prior to the incident and that the information was only uploaded after being provided by the resident's family. The deficiency was further highlighted when the resident, who had a history of cognitive impairment and a BIMS score indicating moderate impairment, was able to leave the facility unsupervised. The family was notified by a hospital that the resident had been there for two hours, while the facility receptionist was unaware of the resident's absence and initially reported the resident as present and fine. The facility's process for determining which residents require supervision when leaving the building relied on assessments and documentation that were incomplete due to the missing diagnosis. Interviews with staff revealed inconsistencies and a lack of clarity regarding the process for transcribing admitting diagnoses and updating resident records. The MDS coordinator and DON both indicated that the failure to enter the dementia diagnosis was due to missing or unreviewed paperwork at the time of admission. The facility's own policy required that all relevant medical information be documented promptly to ensure proper care planning, but this was not followed in the case of this resident, resulting in incomplete and inaccurate records.