Inaccurate Documentation of Resident Temporary Absences
Penalty
Summary
The deficiency involves the facility’s failure to maintain an accurate medical record for one resident regarding temporary absences from the facility. The resident had a history and physical dated 12/12/25 indicating they could make their needs known and make medical decisions, and a physician’s order dated 7/5/25 allowing them to go out on pass for therapeutic purposes. An MDS assessment showed a BIMS score of 15, indicating the resident was cognitively intact. The resident’s Release for Temporary Absence form documented multiple days on which the resident left the facility, with specific departure times recorded. However, on numerous dates listed in November and December, the resident’s Release for Temporary Absence form either had illegible return times or no return times documented at all. For example, on several days the resident’s departure time was recorded, but the return time was missing or not legible. Despite this, a Social Services Progress Note dated 12/9/25 stated that the resident was able to go out on pass every day for more than six hours a day, which conflicted with the incomplete documentation on the temporary absence form. Interviews with staff and the resident confirmed the inconsistencies in the record. The resident stated they received a copy of their medical records and verified they were able to go out on pass every day for more than six hours. The receptionist confirmed that the resident signed out and back in at the reception desk, but acknowledged that some return times were not documented on the form. The Social Services Director stated the receptionist left at 1900 hours and verified that some dates lacked return times, explaining that when the resident returned after 1900 hours there was no staff at reception to sign them back in. The ADON also verified that some return times were missing, stated the resident usually returned around 1800 hours, and indicated the resident should have been signing back in at the nursing station when the receptionist was no longer present. These findings showed the medical record did not accurately reflect the resident’s temporary absences and returns.
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