Incomplete and Inaccurate Medical Record Documentation for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurate medical records in accordance with accepted professional standards for two residents. For one resident with paraplegia, multiple stage 4 pressure ulcers, local skin infection, and severe protein-calorie malnutrition, the medical record initially contained only a few wound notes despite weekly wound care visits. The wound care NP reported that the facility changed electronic systems and that prior wound notes had not transferred into the EMR; the DON later produced printed wound notes that had not been in the record. For the same resident, a change-in-condition note documented hypotension and critical labs with normal respiratory rate and oxygen saturation and no mention of breathing problems, while hospital records from the same day documented shortness of breath and use of a non-rebreather mask at 15 L/min. The RN who sent the resident out stated the resident was having respiratory issues and acknowledged he failed to document this. Additional documentation gaps for this resident included incomplete GNA task records for colostomy output, despite an order to monitor bowel movements every shift. Several shifts in December, January, and February lacked documentation of bowel movements, and the DON stated that if tasks were not signed off, they were not done. A complaint alleged the resident could not keep food down; although there was a PRN order for ondansetron for nausea and vomiting and staff and the physician both recalled an episode of vomiting, there was no nursing documentation of nausea or vomiting in the medical record. Another complaint alleged the facility failed to hold mandated care plan meetings; while there was a letter inviting the family to a care plan meeting on a specific date, there was no documentation in the medical record that the meeting occurred, and the regional social worker confirmed there were no social work notes and that the meeting should have been documented in the assessment section. For a second resident admitted in October 2025, the medical record did not contain documentation that a care plan meeting was held after admission. The EMR’s miscellaneous section contained only a care plan invitation letter for a meeting scheduled in January 2026, with nothing documented for the months immediately following admission. The regional social worker confirmed there was no documentation related to a post-admission care plan meeting for this resident and that only the January meeting notes could be found. These omissions collectively demonstrate that the facility did not maintain complete, accurate, and properly filed medical record documentation for assessments, treatments, changes in condition, and care plan meetings for the residents reviewed.
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