Incomplete Neurological and Wound Care Documentation in Medical Record
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurate medical records for a resident in accordance with its documentation policy. The facility’s policy titled “Documentation in Medical Record” (revised 12/2022) required licensed staff and interdisciplinary team members to document all assessments, observations, and services provided, ensuring documentation was accurate, relevant, and complete. For one resident who had an actual fall with no injury and poor balance, the care plan dated 3/20/24 included an intervention to complete neuro-checks. Review of this resident’s Neurological Flowsheet showed missing entries under the every-eight-hours section for items numbered 17 and 18. During an interview and concurrent closed medical record review with the DON and ADON, the DON verified that the neurological assessments should have been completed and documented. Further review of the same resident’s Order Summary Report showed physician orders dated 3/12/24 for treatment of a right above-eyebrow laceration with betadine daily for 21 days, and for daily monitoring of a deep purplish discoloration on the left side of the body for 30 days. Examination of the Treatment Administration Record (TAR) for 3/24/24 revealed no entries documenting the eyebrow laceration treatment or the monitoring of the purplish discoloration on that date. In a subsequent interview and concurrent record review with an LVN, the LVN acknowledged the lack of entries on the TAR for that day and stated she would need to investigate further, as she was unsure if she had been out of the facility that day. The Administrator and DON were later informed of and acknowledged these findings.
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