Incomplete and Inaccurate Medical Records and Documentation
Penalty
Summary
The facility failed to ensure that medical records were complete and accurate for four residents reviewed. One resident was admitted from a hospital with multiple diagnoses, including weakness, hemiparesis, cognitive decline, and multiple chronic conditions. There was no admission assessment or nursing note documenting the time of arrival or any assessment by a licensed nurse during the five hours the resident was in the facility before being transferred to another facility. Both the family member and facility staff confirmed that the resident was not assessed by a nurse during this period, and the medical record lacked any documentation of an assessment or admission note. Additionally, three other residents reported not receiving adequate showers or bed baths, with one stating they had not received a shower or bed bath for approximately two weeks. Review of the facility's shower documentation revealed inaccuracies and alterations, including the use of correction tape and inconsistent signatures compared to staff assignment sheets. The facility's own policy requires that each resident's medical record accurately reflect the care and services provided, with documentation completed at the time of service or by the end of the shift, which was not followed in these cases.