Incomplete and Inaccurate Medical Record Documentation for Neuro Checks and Post-Operative Wound Care
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurate medical records in accordance with accepted professional standards for two residents. For one resident admitted in October 2025 with a history of cerebral infarction and left-sided hemiplegia/hemiparesis, the medical record showed multiple unwitnessed falls on 10/28/25, 11/2/25, 11/27/25, and 12/26/25, but no neurological assessments (neuro checks) were found in the medical record following these events. During interviews, an RN stated that neuro assessments were either written on a piece of paper sent to the Interim DON’s office or sometimes entered in the vital signs section, and acknowledged uncertainty about the process. The Interim DON reported that neuro assessments were kept with the fall investigation packets in the DON’s office and confirmed they were not part of the resident’s medical record, acknowledging that they would not be accessible in the medical record if a physician requested them on a weekend. The Medical Director stated that neuro assessments should be part of the medical record and expressed disapproval that such information was kept separately. For a second resident who sustained a right hip fracture after a fall and was sent to the hospital, the hospital discharge summary documented an open reduction internal fixation of the right femoral neck fracture. Facility wound assessments documented that the surgical wound initially had staples and later that the surgical site was resolved, but there was no documentation in the medical record of when the staples were removed. Additionally, NP progress notes from 12/2/25 to 1/6/26 documented under skin assessment that the staples were clean, dry, and intact, which was inaccurate because the staples had been removed sometime between 11/11/25 and 11/24/25. These documentation gaps and inaccuracies were confirmed with the VP of Operations and discussed with the Medical Director.
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