Inaccurate Medical Record Documentation and Incorrect Diagnosis Noted
Penalty
No penalty information released
The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.
Summary
The facility failed to maintain accurate and complete medical records for a resident, as evidenced by incorrect documentation in the discharge plan and an inaccurate diagnosis associated with a prescribed medication. Specifically, the discharge plan for the resident incorrectly listed a treatment order for a right second toe amputation site, despite the resident not having undergone such an amputation. Additionally, a physician's order for Ropinirole (Requip) was documented with a diagnosis of Parkinson's disease, when the resident's actual diagnosis was restless leg syndrome. These inaccuracies were confirmed by the facility administrator during the survey process.