Incomplete and Inaccurate Medical Records for Wound, Dental, and Hospice Care
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurate medical records for multiple residents. For one resident with severe cognitive impairment, multiple chronic conditions, and a documented skin tear to the left outer/lateral leg, the care plan and weekly non‑pressure skin grids consistently identified the wound on the left leg with specific measurements and drainage descriptions. However, a series of weekly Wound Nurse Practitioner progress notes from December through March inaccurately documented the wound as being on the right lateral leg, despite physician orders and nursing staff confirming the wound was on the left lower leg. An LPN verified during interview that the WNP documentation did not accurately reflect the actual wound location being treated. For another resident with multiple chronic diagnoses and no documented cognitive deficit, the comprehensive and quarterly MDS assessments indicated no issues with teeth, mouth or facial pain, or chewing difficulty. The care plan later identified the resident as being at risk for dental or chewing problems related to poor dental hygiene and included interventions such as arranging periodic dental consults and follow‑up dental visits. The medical record showed a refusal of dental services on one date and no documented evidence of a dental visit since admission. However, the facility’s contracted dental assistant had in fact seen the resident for an annual visit, performed a cleaning, and applied silver diamine fluoride to several teeth, with follow‑up dependent on insurance. During interview, the social worker acknowledged that this dental progress note was not in the resident’s medical record and was likely only available in email. A third resident, admitted with cerebral infarction and asthma and later enrolled in hospice, also had incomplete documentation in the medical record. Hospice documentation for this resident was not uploaded into the resident’s medical record and was instead maintained in email, as confirmed by facility staff. Further interview revealed that the medical records position had been eliminated, resulting in resident documents remaining in email and not being incorporated into the official medical record. Staff also confirmed that there was no medical records policy addressing the completeness of medical records, contributing to the absence of required hospice and dental documentation and the inaccurate wound location documentation in the residents’ charts.
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