Inaccurate Psychiatric Telemedicine Documentation
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 ensure complete and accurate medical records for a resident, as evidenced by incorrect information documented in the psychiatric telemedicine notes. Specifically, the history of present illness (HPI) section in multiple psychiatric notes contained inaccurate details regarding the resident's age, admission date, first name, and health care surrogate's name. These inaccuracies were attributed to the HPI information being copied from another resident with the same surname. The remainder of the notes appeared correct for the resident in question. The Director of Nursing acknowledged the error during the investigation.