Failure to Document Resident Incidents and Missing Medications
Penalty
Summary
The facility failed to maintain accurate and complete medical records for two residents in relation to significant incidents. For one resident with diagnoses including muscle wasting, repeated falls, and disorientation, there was no documentation in the medical record regarding the reported disappearance of $105 from a pouch attached to the resident's walker. The resident, who had no cognitive impairment according to the BIMS assessment, reported the missing money to the Administrator after returning from the hospital, but this event was not recorded in the resident's records. For another resident with muscle wasting, wheelchair dependence, nerve damage, and moderate cognitive impairment, staff discovered two missing tramadol tablets during a narcotic count. Despite this, there was no documentation in the resident's medical record regarding the missing medication. The facility's own Charting and Documentation policy requires that all incidents, changes in condition, and events involving residents be documented in the medical record, but this was not followed in these cases.