F0842

D

Incomplete and Inaccurate Medical Records and Documentation

Rockville, Maryland Survey Completed on 01-14-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to maintain complete and accurate medical records in accordance with accepted professional standards for multiple residents. For one resident who changed rooms, the census section showed a room switch on 9/18/25 and a psychotherapy note on 9/23/25 documented that the resident loved the new room and was adjusting well, but there was no documentation in the miscellaneous, assessment, or progress notes sections about the room change or the request to change rooms. The new roommate’s record also lacked any documentation of receiving a new roommate on that date, and the only roommate assessment forms for either resident were from prior years. A handwritten transfer form related to the room change was later found in the DON’s office rather than in the resident’s medical record, and both the social work assistant and the Interim DON acknowledged it should have been in the medical record.

Another deficiency was identified when a resident with a Foley catheter was observed in bed with the drainage bag hanging on the side of the bed without a dignity bag, and urine was visible. The resident’s Treatment Administration Record contained a physician’s order for catheter care requiring use of a dignity Foley bag every shift, and the TAR showed nurses’ initials for several days indicating that a dignity bag was in use each shift, despite the observation that it was not in place. In a separate case, review of another resident’s record related to a complaint of an emergency room visit for an allegation of sexual abuse showed no documentation of the ER visit in the assessments, progress notes, or paper record. The Acting DON later obtained the ER documentation from a regional health information exchange and confirmed that there was no documentation of the ER visit in the resident’s medical record.