F0842

E

Incomplete and Inaccurate Medical Records, Missing Assessments, and Absent Consult Documentation

Randallstown, Maryland Survey Completed on 02-09-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to maintain complete, accurate, and readily available medical records in accordance with accepted professional standards. Surveyors found that multiple residents who were identified as independent smokers did not have required Safe Smoker Assessments completed at admission or at required quarterly intervals, despite being listed on the facility’s smoker list. For one resident with a history of falls, several Fall Risk Evaluations were incomplete, lacking required documentation of medications used and gait analysis, even though the resident had a known fall history. Another resident’s personal belongings were not documented anywhere in the medical record or paper chart, despite the resident reporting missing clothing and the facility’s expectation that belongings be recorded on a personal belongings form at admission and updated as needed.

The surveyors also identified serious inconsistencies and omissions in documentation related to advance directives, capacity determinations, and hospital transfers. One resident had two conflicting Maryland MOLST forms in the paper chart—one indicating Do Not Resuscitate/Do Not Intubate and another indicating attempt CPR—while the electronic medical record contained an active physician order and uploaded MOLST reflecting full code. This conflicting documentation extended into other records, including a care conference note and dialysis communication forms, where the resident’s code status was alternately documented as full code and DNI. For two other residents, Physician Certifications of incapacity were completed with only one physician signature, despite the requirement for two qualified professionals to certify lack of decision-making capacity.

Surveyors further found that the facility failed to maintain and retain outside consult documentation from urology and other providers in residents’ medical records. For one resident with a urinary catheter, no urology specialist documentation could be found in either the electronic or hard-copy chart, even though facility documentation referenced urology visits and refusals. For another resident reviewed in connection with a neglect complaint, the DON initially could not provide nurse practitioner notes or urology consult records and could not confirm whether urology records were present in the chart; subsequent review confirmed that urology consults were not in the resident’s medical record until they were later obtained from the outside provider. In addition, for a resident who had two separate hospital transfers, the hospital transfer form contained inconsistent dates, with the transfer date and hospital notification date not matching the dates of the clinical information and vital signs documented on the same form, and the DON was unable to explain these discrepancies. Collectively, these findings show that the facility did not ensure that medical records, including assessments, code status documentation, capacity certifications, personal property records, outside consult notes, and transfer forms, were complete, accurate, and maintained in accordance with professional standards.

Finally, the surveyors noted that for one resident who called 911 and was transported to the hospital, the DON initially stated there was no transfer form because the resident dialed 911, but then produced a transfer form that contained conflicting dates and times for the transfer and clinical data. The DON acknowledged that the information on the transfer form should have been reviewed to ensure accuracy and that it should reflect the resident’s status at the time of transfer. Across these various findings, the surveyors determined that the facility failed to maintain medical records that accurately and completely reflected residents’ conditions, services provided, and external consultations, as required by accepted professional standards and practices.