Failure to Maintain Complete and Accurate Medical Records for Resident with Change in Condition
Penalty
Summary
The facility failed to maintain complete, accurate, and systematically organized medical records for a resident who experienced a significant change in condition. The resident, who had multiple complex diagnoses including Type 2 Diabetes Mellitus with neurological complications, chronic kidney disease, fibromyalgia, epilepsy, osteoporosis, and Parkinson's disease, experienced increased pain, bruising, and swelling in her lower left extremity following an off-premises dental appointment. Staff interviews and record reviews revealed that the resident's pain was not accurately documented in the medical record, with facility pain assessments consistently recorded as 0 out of 10, despite hospice nurse notes indicating pain levels as high as 10 out of 10. Additionally, the administration of as-needed pain medication was not supported by corresponding pain assessments in the medical record. The medical record lacked critical documentation, including a description of the injury, details of the event that led to the change in condition, hospice nurse progress notes, and after-visit summaries from the dental provider. Staff failed to capture the resident's account of the incident and did not document ongoing monitoring or assessments following the change in condition. Interviews with facility staff, including the DON, ADON, and LPNs, confirmed that documentation was incomplete or missing, and that expected practices such as documenting assessments, pain ratings, and communication with hospice or medical providers were not followed. The facility also did not provide a policy related to charting, documentation, or medical record filing when requested. The deficiency was further evidenced by discrepancies between hospice and facility documentation, with hospice records reflecting significant pain and changes in condition that were not mirrored in the facility's records. The facility's failure to maintain accurate and complete medical records was acknowledged by both the DON and the Nursing Home Administrator, who confirmed that the resident's medical record was not complete and that documentation practices did not meet expectations. The absence of hospice notes and other essential documentation in the resident's chart was also confirmed during the survey.