Incomplete and Inaccurate Clinical Record Documentation for Two Residents
Penalty
Summary
The facility failed to ensure that clinical records were complete and contained accurate information for two residents. For one resident, review of the Medication Administration Record (MAR) and Treatment Administration Record (TAR) for November 2025 showed missing documentation for several required assessments and interventions, including diabetic foot checks, head of bed elevation for shortness of breath, encouragement of deep breathing for cough, and monitoring for side effects of psychotherapeutic medications during specific shifts. Additionally, documentation of the evening meal was missing on two dates in the resident's eating record. For another resident, the clinical record included a physician order for sliding scale insulin administration based on finger stick blood sugar (FSBS) results four times daily. However, the TAR for November 2025 lacked evidence of FSBS results and whether sliding scale insulin was administered or needed for several morning treatments. The Market Lead Clinical Specialist was unable to locate the missing documentation elsewhere in the record, and the surveyor confirmed these findings.