Failure to Maintain Accurate and Complete Medical Records
Penalty
Summary
The facility failed to maintain accurate and complete medical records for two of three residents reviewed, resulting in multiple documentation deficiencies. For one resident with diagnoses including dementia, dysphagia, and frontal lobe deficit, the history and physical documented independent movement of all extremities, while the Minimum Data Set indicated upper and lower extremity impairment on one side and a need for full assistance with daily activities. Additionally, after this resident experienced a fall, there was no fall assessment, neuro checks, change in condition documentation, post-fall assessment, or care plan interventions related to the incident, despite the resident's family being notified of the fall. Further review revealed significant gaps in the Activities of Daily Living (ADL) documentation for this resident, with multiple days and shifts lacking any entries for essential care tasks such as eating, dressing, and hygiene. For another resident who was on hospice care, the ADL task list showed only sporadic documentation of showers, despite hospice being responsible for providing them on specific days. Meal intake documentation was also found to be inaccurate, with discrepancies between what was charted and what was reported by the CNA who actually assisted the resident. Interviews with staff confirmed that CNAs were sometimes documenting care for residents they did not personally assist, and that required documentation was not consistently completed before the end of each shift. Both the DON and ADON acknowledged these documentation lapses, noting that the ADL task list should be fully completed daily and that only the CNA providing care should document for the resident.