Inaccurate Therapy Documentation on Long Term Care Evaluation Forms
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurate medical records for a resident in accordance with accepted professional standards. The resident was originally admitted with diagnoses including chronic obstructive pulmonary disease, osteoarthritis, and chronic pain syndrome, and had documented capacity to understand and make decisions, with intact cognitive functioning on a subsequent MDS. The MDS also indicated the resident required assistance with toileting hygiene, showers, and dressing, and was independent with ambulating 150 feet. According to the Interim Rehab Director, the resident was discharged from physical and occupational therapy on 5/19/2025 and did not receive these therapies after that date. During review of the resident’s Long Term Care Evaluation forms, the DON identified that weekly evaluations dated 6/8/2025 and 6/29/2025 documented that the resident continued to participate in occupational and physical therapy as ordered by the physician, despite the resident not receiving these services during that period. The DON stated that the Long Term Care Evaluation is a weekly assessment of resident progress for continuation of care and acknowledged that these evaluation forms were not documented accurately. This inaccurate documentation conflicted with the facility’s policy titled “Completion and Correction,” which requires medical record entries to be complete, legible, descriptive, and accurate, and to ensure that medical records are complete and accurate.
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