Incomplete and Inaccurate Clinical Documentation for Resident Elopement, Room Requests, and Discharge Planning
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurate medical records for two residents in accordance with professional standards. For one resident with severe sepsis, pneumonia, anxiety disorder, depression, heart failure, and a BIMS score indicating moderate cognitive impairment, the resident left the facility without staff knowledge or permission. Nursing progress notes documented that the resident had left the facility and had not returned, and later that the resident returned from the hospital with a clavicle fracture, swollen eye, and arm sling. However, the event was documented as a departure Against Medical Advice (AMA) in an IDT note, even though staff were unaware of the resident’s departure at the time and there was no documentation of the required AMA elements such as the resident’s request to discontinue care, explanation of clinical risks, or the resident’s consent and post-discharge arrangements, as required by the facility’s AMA discharge policy. The same resident had also requested a room change due to a bathroom issue with a roommate. The case manager stated that the resident had complained about the bathroom issue and had been offered a room change, which the resident then declined. Despite this, there was no documentation in the clinical record of the resident’s request, the offer of a room change, or the resident’s decision, resulting in an incomplete record of the resident’s concerns and the facility’s response. For another resident admitted with peripheral vertigo, chronic kidney disease, muscle weakness, difficulty walking, and cognitive symptoms, the clinical record lacked documentation of communication between the Social Services Director and an external case manager regarding discharge planning to an independent living facility. The Social Services Director reported calling the case manager about finding an independent living facility but could not recall the exact date. The external case manager reported being informed that an independent living facility had been found and requested the name and address to arrange a tour, expecting the information via text message, but later learned the resident had already been discharged that afternoon. The resident’s discharge summary documented discharge to an independent living facility, but the clinical record did not contain documentation of the communication and coordination between the facility and the external case manager related to this discharge.
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