Incomplete and Inaccurate Clinical Records and MAR Documentation
Penalty
Summary
The facility failed to maintain complete and accurate clinical records for two residents with significant psychiatric diagnoses, including schizoaffective disorder and bipolar disorder. For one resident, provider progress reports and nursing notes related to changes in medical condition were not available in the clinical record in a timely manner. There was no documentation of the rationale or provider responsible for discontinuing a key medication, and psychiatric documentation was delayed by up to three weeks before being uploaded to the resident's record. Additionally, there was no evidence that the resident was seen by a psychiatric provider within 24 hours of a change in condition, as required. Medication Administration Records (MARs) for both residents contained numerous blank entries over several months, with one resident having over 100 blank entries and the other over 20. Staff interviews confirmed that MARs should not have blank entries, as this prevents determination of what care and treatment was provided. Furthermore, one resident's MAR incorrectly indicated hospitalization on a specific date, despite no supporting documentation in the clinical record. A psychiatric assessment progress report for one resident was found to be inaccurate, with documentation referencing an incident before it occurred and appearing to be copied from another date. Both the Mental Health Case Manager and the Director of Nursing acknowledged that provider progress notes were not uploaded in a timely manner and that documentation in the clinical records was incomplete and inaccurate. Facility policy requires that documentation in the medical record be complete and accurate, which was not met in these instances.