Failure to Maintain Complete and Accurate Clinical Records
Penalty
Summary
Facility staff failed to maintain complete and accurate clinical records for four residents, resulting in multiple documentation deficiencies. For one resident with wounds requiring daily treatment, the Treatment Administration Record (TAR) lacked signatures on several days, and there was no alternative documentation in the progress notes to confirm whether treatments were completed. Interviews with nursing staff revealed uncertainty about whether unsigned treatments were performed or simply not documented, and one nurse reported that treatments were sometimes missed at shift change. The resident was unable to recall receiving treatments or even having wounds, further complicating verification. Another resident experienced a fall, but there was no documentation in the clinical record regarding the incident, the assessment performed at the time, or the circumstances surrounding the fall. Although an incident form existed, it was not part of the medical record, and no neurological assessments were documented as required by facility policy. Both the LPN unit manager and the DON confirmed the absence of required documentation and stated that standard practice was not followed. The facility's fall prevention policy specifically required documentation of all assessments and actions in the clinical record, which was not done in this case. Additional deficiencies included missing documentation of a resident's orthopedic appointment and incomplete neuro checks following a fall. The orthopedic appointment note was not present in the clinical record until it was later obtained from the physician's office, and staff could not initially locate it. For neuro checks, the documentation labeled as such only included vital signs and omitted required neurological assessments, with staff acknowledging that the records were incomplete and not in accordance with expectations. Another resident who sustained a hip fracture after a fall had no documentation in the clinical record regarding the fall's circumstances, staff assessments, or actions taken, with only a brief provider note and an incomplete post-fall review present. The DON confirmed these documentation gaps and acknowledged that incident reports were not part of the clinical record.