Incomplete Medical Record Documentation for Resident Diagnoses
Penalty
Summary
The facility failed to maintain complete and accurate medical records for one resident. Specifically, the resident's face sheet did not include the diagnoses of Primary Osteoarthritis Left Shoulder, Primary Osteoarthritis Right Shoulder, and Polyneuropathy Unspecified, despite these conditions being documented in a nurse practitioner's note. The face sheet only listed other diagnoses such as Chronic Respiratory Failure with Hypoxia, Unspecified Protein-Calorie Malnutrition, and Unspecified Combined Systolic and Diastolic Heart Failure. The resident's care plan referenced pain related to immobility, and the resident was noted to have intact cognition based on a recent BIMS score. The omission of these diagnoses from the face sheet was confirmed during an interview with the DON, who acknowledged the importance of having all diagnoses accurately listed for communication with outside providers. The facility's policy requires that each resident's medical record accurately reflect the resident's experience through complete, accurate, and timely documentation. The failure to update the face sheet with all current diagnoses resulted in incomplete and inaccurate medical records for the resident.