Incomplete and Inaccurate Documentation of Resident Incident
Penalty
Summary
The facility failed to ensure that a resident's medical record contained complete and accurate information regarding an incident involving two residents in the memory care unit. According to the documentation, a social service note indicated that the residents were interested in a romantic relationship and were advised to spend time together only in public spaces, with both agreeing to this guidance. However, interviews with staff and the resident's power of attorney revealed that the actual incident involved the two residents being found together in bed, with conflicting accounts about whether they were clothed or unclothed. The note in the medical record did not accurately reflect the details of the incident as described by staff and the resident's family member. Further review showed that the LPN involved was instructed by the previous administrator not to document the incident in the residents' charts, and the previous social services staff could not recall specific details without her notes. The facility's policy requires that all assessments, observations, and care provided be documented accurately, objectively, and completely in the resident's medical record. The lack of accurate and complete documentation in this case resulted in a deficiency, as the medical record did not contain sufficient details about the incident or the residents' responses to care.