Failure to Maintain Accurate and Consistent Medical Records and Treatment Orders
Penalty
Summary
The facility failed to maintain accurate and complete medical records for multiple residents. For one newly admitted resident, the medical record contained no listed medical diagnoses under the diagnoses category, with the medication orders, or in the care plan at the time of review. The DON confirmed that the resident’s diagnoses were not entered at admission and were only added six days later. For another resident with a history of a fall and left femur fracture, physician orders included nonskid strips on the bathroom floor in front of the commode every shift and visual reminders in the bathroom to use the call light for assistance with transfers twice a day. March and April 2026 treatment sheets showed staff signing off twice daily that these interventions were in place. However, the DON verified that this resident did not have fall strips in front of the toilet or a sign as a reminder to call for assistance, and that the facility had removed these interventions from the plan of care after the resident returned from the hospital and was no longer using the bathroom. The DON acknowledged that the corresponding physician orders were not discontinued and that nursing staff continued to document completion of treatments that were not actually in place. For another resident admitted with multiple diagnoses including cerebral infarction, protein calorie malnutrition, adjustment disorder with anxiety, anorexia, GERD, constipation, glaucoma, vascular disease, history of falling, muscle weakness, and difficulty walking, the record showed an in-house Stage II pressure ulcer to the left outer ankle. Active physician orders included one to pad and protect a healed left lateral ankle pressure ulcer twice weekly and as needed, and another to cleanse the left outer ankle and apply duoderm on specified days. The DON confirmed there were two contradicting active orders and that the pad and protect order was present in the physician orders but did not appear on the treatment sheet for staff to sign off.
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