Failure to Maintain Complete and Accurate Psychiatric and Medication Documentation
Penalty
Summary
The facility failed to maintain complete and accurate medical records for a resident with multiple chronic conditions, including type II diabetes, hydrocephalus, vascular dementia, COPD, chronic kidney disease, and a severe cognitive impairment documented on an MDS assessment. Review of this resident’s medical record showed no psychiatric evaluations or notes regarding psychiatric meetings for the previous 12 months, despite the resident receiving psychiatric care through the VA. There was no documentation that the VA psychiatric physician was consulted or informed of pharmacy recommendations related to the resident’s ordered medications, including psychotropic medications, nor any documentation that the VA psychiatric physician was consulted about medications ordered by the facility physician. During an interview, the DON confirmed there was no documentation in the resident’s record to support psychiatric appointments or meetings with the VA physician. She acknowledged that telehealth meetings involving the resident, his wife, facility staff, and the VA physician had occurred on three separate dates, but the facility had no documentation of these encounters, including what was discussed or any recommendations made regarding the resident’s health. This lack of documentation resulted in incomplete and inaccurate medical records for the resident.
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