Incomplete Documentation of Resident Medical Records
Penalty
No penalty information released
The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.
Summary
The facility failed to ensure that medical records for a resident were complete and accurately documented. Specifically, a resident with a diagnosis of locked-in state was admitted with ongoing complex care needs. An incident report noted that the resident was observed with bruising and a complaint of pain on the right thumb. However, a review of the resident's nurse progress notes revealed there was no documentation of an evaluation for the bruising and pain. The Director of Nursing confirmed that the required documentation was missing, indicating that the facility did not maintain complete clinical records as required by policy and regulation.