Failure to Maintain Accurate and Complete Medical Records
Penalty
Summary
The facility failed to maintain complete and accurate medical records in accordance with accepted professional standards, as evidenced by multiple deficiencies identified during a recertification and complaint survey. In one instance, a resident who reported having no teeth for years was inaccurately assessed in both the nursing admission assessment and the Minimum Data Set (MDS) assessment, with documentation failing to indicate the resident was edentulous. The MDS coordinator relied on documentation from other disciplines rather than direct assessment, resulting in incorrect coding of the resident's oral status. Another deficiency involved a resident whose medical record lacked timely and complete provider notes. Progress notes indicated that a nurse practitioner had seen the resident and ordered medication, but the corresponding provider notes were missing from the electronic medical record. When the surveyor requested these notes, they were subsequently uploaded with creation dates much later than the effective dates, confirming that the documentation was not completed in a timely manner and was not part of the resident's record at the time of care. Additional findings included incomplete documentation of therapy services and inaccurate physician orders. One resident had a physician order for physical therapy 3-5 times per week, but therapy was only provided twice in one week without documentation explaining the missed sessions, despite the resident being available for other therapies. Another resident had an active physician order for monitoring anticoagulant medication, but there was no corresponding order for the medication itself, and the medication was not listed on the MAR, care plan, or MDS assessments. These deficiencies demonstrate failures in maintaining accurate, complete, and timely medical records for residents.