Incomplete and Inaccurate Medical Record Documentation
Penalty
Summary
The facility failed to maintain complete and accurate medical records for two residents. For one resident, the care plan documented by activity staff stated that the resident did not eat meat, fish, eggs, or caffeine due to religious beliefs. However, the dietary order specified a lacto-ovo vegetarian diet, which includes eggs and dairy. The resident's Medical Power of Attorney confirmed that eggs were an important part of the resident's diet, and the Director of Activities acknowledged that the care plan needed updating to accurately reflect the resident's current dietary preferences, which included eggs. For another resident, record review revealed multiple inaccuracies in the documentation of bladder incontinence status. Despite the resident having an indwelling urinary catheter for obstructive uropathy, documentation inconsistently recorded the resident as incontinent on several dates, rather than indicating that continence could not be rated due to the catheter. The Director of Nursing verified the presence of the indwelling catheter and recognized the need for additional training for CNAs, as some were new and had not documented the resident's status correctly.