Failure to Maintain Complete and Accurate Medical Record for Resident Who Left and Did Not Return
Penalty
Summary
The facility failed to maintain complete and accurate medical records for a resident admitted with diagnoses including alcoholism and diabetes. The resident was admitted shortly before a holiday and remained in the facility for approximately two days before leaving and not returning. The resident’s record did not contain an Against Medical Advice (AMA) form, and there was no documentation of the resident signing out or being taken out of the facility. The social services staff member stated the resident left after about two days without signing an AMA form, and the AMA form itself was not present in the medical record. On the day the resident left, the day-shift RN reported that the resident mentioned his daughter might come to take him out for the holidays. Around lunchtime, the RN went to perform a blood sugar check but found the resident was not in his room and assumed the daughter had taken him out on pass, yet did not document the resident’s absence or inability to locate him. A CNA reported seeing the resident’s daughter take the resident out and stated she informed the day-shift RN, but this was also not documented. The PM-shift RN later checked the sign in/out sheet and found no record of the resident signing out or of who took him out, contacted the DON and the family, and learned the resident refused to return, but did not document these events in the progress notes. The DON stated it was important to document accurately in the resident’s record, especially when a resident was out of the facility, and the facility’s policy requires organized, accurate, and complete written records for each resident.
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