Failure to Maintain Accurate and Complete Medical Records
Penalty
Summary
The facility failed to maintain accurate and complete medical records for two residents. For one resident with dementia, osteoarthritis, chronic pain, and a left femur fracture, discrepancies were found between the times documented in the electronic medical record and the facility's after-hours provider notification records regarding falls and subsequent provider notifications. The Corporate Nurse was unable to explain why the times did not match and acknowledged the documentation was not accurate. For another resident with quadriplegia, chronic pain, anxiety, and depression, significant gaps were identified in the Activities of Daily Living (ADL) flow sheet documentation. Missing entries were noted for bathing, bed mobility, dressing, hygiene, toileting, and eating over an eleven-day period. The DON confirmed that the documentation was unacceptable and attributed the issue in part to agency staff not having access to the electronic medical record, as well as the resident's short stay at the facility.