Failure to Accurately Document Resident Death in Medical Record
Penalty
Summary
The facility failed to maintain a complete and accurate medical record related to a resident death when documentation of the death was missing from the progress notes. Resident J, who had diagnoses including end stage renal disease, had a Death in Facility MDS entry completed on 12/11/25. A progress note on that date at 9:39 a.m. documented that the resident left the facility to go to dialysis with no acute distress noted at that time, and there were no further progress notes entered afterward. During interview, the Director of Nursing stated that the resident went to dialysis, coded there, died that day, and did not return to the facility, and acknowledged that the resident’s death had not been documented in the progress notes, although the discharge would have been reflected in the midnight census. This deficiency was identified for 1 of 5 residents reviewed for accidents (Resident J) and relates to Intake 2712287 under 3.1-50(a)(1), which requires safeguarding resident-identifiable information and maintaining medical records in accordance with accepted professional standards.
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