Failure to Maintain Complete and Accurate Medical Records for Emotional Distress and Dental Status
Penalty
Summary
The facility failed to maintain complete and accurate medical records for two residents. For one resident with a BIMS score indicating no cognitive impairment, an incident of resident-to-resident verbal abuse in the dining room was reported to the state but not documented in the resident’s medical record. The incident involved another resident yelling profanities, including the F-word and telling the resident to “shut up,” causing the resident to cry and return to their room. The resident, who has depression, reported feeling overwhelmed and was observed tearing up when recounting the event. There was no documentation in the medical record of the altercation, the resident’s crying episodes, or any monitoring of the resident’s emotional response such as anxiety, fear, or increased depression. For another resident, the facility’s MDS documented no obvious or likely cavities or broken natural teeth, despite other records and observations indicating significant dental problems. The resident’s care plan documented poor dentition with obvious tooth decay, and on interview the resident reported dental issues and a plan to have all teeth extracted and replaced with dentures. Direct observation showed multiple black and brown broken teeth worn down to the gum level, with only six remaining chipped, darkly discolored teeth. The administrator confirmed that the MDS coding for this resident’s dental status was incorrect and inconsistent with the resident’s other medical records and current oral health condition.
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