Failure to Maintain Accurate Medical Records for Resident Behaviors and Allegations
Penalty
Summary
The facility failed to maintain medical records according to accepted professional standards for one resident. The facility's policy on charting and documentation requires that all pertinent changes in a resident's condition, reactions to treatments, and behaviors be accurately and completely documented in the clinical record. However, a review of the clinical record for a resident with multiple diagnoses, including Multiple Sclerosis and Acute Respiratory Failure, revealed significant gaps in documentation related to reported inappropriate sexual behaviors and alleged abuse. Multiple staff witness statements described incidents where the resident made inappropriate and offensive remarks, attempted to touch staff, and engaged in other concerning behaviors. These incidents were reported by several licensed nurses and nurse aides, who documented their observations and actions in separate incident witness statements. Despite these detailed accounts, there was no corresponding documentation in the resident's clinical record for an extended period, specifically from November through the following year, regarding the inappropriate sexual behaviors or the actions taken in response. Additionally, the facility's investigation into an allegation of sexual abuse included several staff witness statements that contained information not reflected in the resident's clinical record. The lack of documentation in the clinical record failed to provide a complete account of the resident's care and behaviors, as required by facility policy and regulatory standards. This deficiency was cited under relevant state codes for medical records and nursing services.