Inaccurate Electronic Diagnosis List for Resident With Dementia and Anxiety
Penalty
Summary
Surveyors identified a deficiency in the facility’s maintenance of complete and accurate medical records for one resident. The resident’s face sheet listed multiple diagnoses, including hyperlipidemia, cerebral infarction, encephalopathy, and hypertension. The admission MDS documented a BIMS score of 7/15, indicating severe cognitive impairment, and showed the resident required substantial/maximal assistance with most ADLs such as sit-to-stand, chair-to-bed, and toilet transfers. A physician progress note dated 12/01/2025 identified dementia with anxiety as one of the resident’s active medical problems. However, review of the resident’s electronic medical diagnoses list on 01/06/2026 showed that dementia with anxiety was not included as an active diagnosis. During observation, the resident was seen sitting in a wheelchair near the nursing station and was unable to state his medical problems due to low cognitive function. In an interview, the DON confirmed that the resident had dementia with anxiety, that the primary care physician had documented this diagnosis, and that the diagnosis was missing from the electronic medical diagnosis list. The DON acknowledged the inaccuracy and stated she was responsible for ensuring residents had accurate medical diagnosis lists. The facility’s “Charting and Documentation” policy required that all services and changes in a resident’s medical condition be documented in the medical record.
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