Inaccurate Weight Documentation and Discharge Records
Penalty
Summary
The deficiency involves the facility’s failure to maintain accurate and consistent medical records, specifically related to weight documentation and discharge records. For several residents, weight tracking showed implausible or inconsistent values that facility staff, including the DON, later characterized as documentation errors. One resident’s weight record reflected a gain of over 50 pounds within a one‑month period, and another resident’s record showed a large weight gain over a short period that the DON acknowledged appeared to be inaccurate. The DON stated it was her responsibility to ensure nurses accurately document resident weights and that her expectation was that staff correctly document resident weights. The facility also failed to maintain accurate discharge documentation for another resident. This resident was admitted in late August and transferred out of the facility to the hospital in early September for a wound follow‑up, as reflected in a physician order and the DON’s interview. However, the resident’s MDS indicated a discharge to home/community rather than to the hospital, and a physician discharge summary note was entered in the progress notes more than two months after the actual transfer date. The DON stated she did not know why the discharge summary note was entered on the later date or why the MDS showed a discharge to home/community, and she indicated that nurses were responsible for accurate assessments and the MDS coordinator was responsible for MDS accuracy. The Administrator confirmed the resident had been scheduled for discharge home but was instead sent to the hospital after a change in condition, and that the MDS should have reflected a discharge to the hospital.
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