Incomplete and Inaccurate Medical Record Documentation
Penalty
Summary
The facility failed to maintain complete, accurate, and systematically organized medical records for three of six sampled residents. For one resident, physician orders required daily weights for two days, but documentation was inconsistent: the Medication Administration Record (MAR) was initialed as if weights were obtained, yet no actual weights were recorded for the specified dates. Additionally, the resident's care plan indicated a hospice referral, and progress notes showed the resident and family requested hospice services, but there was no documentation confirming hospice services were initiated or further follow-up, and staff acknowledged that changes in the resident's wishes regarding hospice were not documented. Another resident's care plan specified no male caregivers or nurses, yet a male RN documented an assessment in the resident's chart, despite not entering the room, resulting in inaccurate documentation. For a third resident, the admission/readmission assessment was incomplete, missing key information such as sensory, mood, behavior, nutrition, and other health status areas. Staff confirmed the assessment was not completed timely and lacked required details. These deficiencies were identified through interviews and record reviews, and the issue of incomplete admission assessments was noted as a repeat citation from previous surveys.