F0842

D

Failure to Document Family Medication Concern in Resident Medical Record

Lancaster, California Survey Completed on 01-30-2026

Penalty

No penalty information released

Summary

The facility failed to maintain an accurate and complete medical record for a resident by not documenting a family member’s report and related discussion about the resident’s medications. The resident was admitted with diagnoses including orthopedic aftercare, unspecified psychosis, and a history of falls. The admission History and Physical documented that the resident did not have capacity to understand and make decisions, while the subsequent MDS assessment indicated intact cognitive skills for daily decisions, a need for staff supervision with hygiene, toileting, and showering, and use of antipsychotic medication. On the second day after admission, the resident’s family member reported finding pills in a clear plastic bag and communicated this concern, including a photo, to the Social Service Assistant.

The Social Service Assistant later confirmed that the family member had spoken with her about the resident’s medications and had shown her a picture of a clear plastic bag with pills, reporting that the resident had been caught with pills in the general acute care hospital. The Social Service Assistant acknowledged that she did not document this conversation or the concern in the resident’s medical record. Review of the facility’s Charting and Documentation policy showed that all changes in a resident’s medical, physical, functional, or psychosocial condition, as well as events or incidents involving the resident, must be documented in the medical record to facilitate communication among the interdisciplinary team. The DON stated that the Social Service Assistant should have documented the concerns and conversation with the family member and that the absence of this documentation rendered the resident’s medical record incomplete, contrary to facility policy.