Incomplete and Inaccurate Clinical Documentation for Multiple Residents
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurate medical records in accordance with its own documentation policy and accepted professional standards. For one resident with diabetic foot wounds, diabetes, and Parkinson’s disease, the EMR showed multiple missing weekly skin assessments over several months, despite the resident having diabetic foot ulcers and being frequently incontinent of bladder and always incontinent of bowel. Weekly weights were also missing on numerous dates from admission through discharge, and meal intake documentation lacked entries on many days, with no indication that meals were served or refused. Incontinent care documentation for this resident was also absent on several dates, and on one date was marked as not applicable due to an indwelling urinary catheter. For a second resident with a brain injury and severe cognitive impairment, the quarterly MDS indicated the resident was always incontinent of bowel and bladder and had no skin issues. However, weekly skin assessments were missing on multiple dates over a four‑month period. In the incontinent care task documentation, there were days within a 14‑day review period where no incontinent care was documented at all, and several days where incontinent care was documented only once per day. These gaps occurred despite the resident’s documented total incontinence status. For a third resident with multiple sclerosis who was cognitively intact and always incontinent of bowel and bladder, incontinent care documentation in the EMR showed numerous days with no incontinent care recorded. Additional days showed incontinent care documented only once on the 7:00 AM to 3:00 PM shift. During interviews, a CNA stated that documentation needed to be accurate but that many agency CNAs might not complete documentation, and the Administrator and DON confirmed there was missing documentation in resident records. The facility’s policy on documentation required that each medical record contain an accurate representation of the resident’s experiences, with complete, accurate, and timely documentation completed at the time of service or by the end of the shift in which care was provided, which was not followed in these cases.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.