Failure to Accurately Document Resident Diagnosis in Medical Records
Penalty
Summary
The facility failed to maintain accurate and complete medical records for a resident by not documenting the resident's history of scabies in the diagnosis section of the medical record. The resident was admitted and readmitted with multiple diagnoses, including dementia, type 2 diabetes mellitus, and chronic kidney disease. Upon review, the resident's discharge summary from a general acute care hospital indicated a diagnosis of scabies, with instructions to continue ivermectin treatment and maintain isolation. Surveillance data collected at the facility also noted the resident's scabies diagnosis and ongoing treatment. Despite this, the resident's official diagnosis list in the facility's records did not include a history of scabies. During interviews, the DON acknowledged that the diagnosis should have reflected the resident's history of scabies, even if resolved, to provide an accurate synopsis of the resident's condition. The facility's policy required that documentation in the medical record be objective, complete, and accurate, but this standard was not met in this instance, resulting in inaccurate documentation for the resident.