Failure to Maintain Accurate Medical Records for Two Residents
Penalty
Summary
The facility failed to maintain accurate medical records in accordance with professional standards for two residents. For one resident with a diagnosis including bipolar disorder, documentation inconsistencies were identified on two separate days. Despite incidents involving agitation and aggressive behavior, including a heated interaction with another resident and an episode where the resident displayed physical aggression with a knife, the Behavior Monitoring Record for both dayshift periods inaccurately recorded zero instances of agitated behavior. Interviews with involved parties confirmed the presence of agitation and aggression during these incidents, which were not reflected in the official records. For another resident admitted with stroke and aphasia, the facility's records showed multiple discrepancies. Although the resident was under an NPO (nothing by mouth) order, staff documented oral fluid intake on four occasions. Additionally, progress notes contained conflicting information regarding the resident's ability to communicate, with one note stating the resident was aphasic and nonverbal, while also indicating clear speech. Another note referenced recent lab results that did not exist in the resident's chart. The DON confirmed that the documentation of oral intake was erroneous and that the resident was nonverbal during the stay.