Inaccurate Medical Record Documentation During Resident Elopement
Penalty
Summary
The facility failed to ensure that medical records were complete and accurate in accordance with professional standards for one resident. Specifically, documentation on the resident's Visual Checks form indicated that staff observed the resident in his bedroom at regular intervals, even though the resident had actually eloped from the facility during that time. The Visual Checks form showed the resident was present in his room every fifteen minutes from 1:00 PM to 1:45 PM, while other records and staff interviews confirmed that the resident was missing and later found outside the facility at 1:50 PM. Interviews with staff and review of the resident's records revealed inconsistencies between the Visual Checks documentation and the actual events. Staff acknowledged that the resident was missing at 1:30 PM, and the DON confirmed that the documentation did not accurately reflect the resident's whereabouts. The facility's policy required timely, accurate, and comprehensive documentation of care and monitoring, which was not followed in this instance. The inaccurate documentation resulted in a medical record that did not truthfully represent the resident's status during the period of elopement.