Failure to Accurately Document Resident Care and Meal Intake
Penalty
Summary
The facility failed to maintain accurate and complete documentation of care and services provided to three residents. For one resident, a review of records and a facility-reported incident revealed that incontinence care was not documented at several specific times, despite the facility's investigation concluding that care had been provided. Similarly, another resident's records lacked documentation of incontinence care at multiple times, even though the facility determined that the care was rendered. In both cases, the Administrator and DON acknowledged that the lack of documentation was an error and that the care was not properly recorded. Additionally, for a third resident, meal intake percentages were not documented for an entire day, including breakfast, morning snack, lunch, and afternoon snack. The DON confirmed the absence of documentation for these meals and was unable to locate any records for that day. These findings indicate that the facility did not consistently safeguard resident-identifiable information or maintain medical records in accordance with accepted professional standards, as required.