Inaccurate Documentation of Resident Speech Status in Medical Record
Penalty
Summary
The deficiency involves the facility’s failure to ensure accurate, relevant, and complete documentation in the medical record for one resident, as required by its policy on medical record documentation. The facility’s policy, revised on 8/23/23, states that licensed staff and interdisciplinary team members must document all assessments, observations, and services in accordance with state law and facility policy, and that documentation must be accurate and contain sufficient detail about residents’ care and responses to care. For Resident 1, who was admitted on an unspecified date, the history and physical dated 1/11/26 documented that the resident had no capacity to understand and make decisions. The Minimum Data Set (MDS) assessment for this resident documented unclear speech characterized as slurred or mumbled words. Despite the MDS assessment indicating unclear speech, multiple skilled nursing evaluations dated 2/16, 2/18, 2/20, 2/21, 2/22, 2/24, 2/25, 2/27, and 3/1/26 documented that the resident’s speech was clear. During interviews on 3/9/26, LVN 1 stated that the resident was able to answer yes or no when asked about pain, but confirmed that the resident’s speech was not clear as documented. LVN 2, a treatment nurse, reported that when she assessed the resident’s skin, the resident’s speech was not clear. CNA 1 stated that the resident talked a little but was very hard to understand. In a subsequent interview, the DON reviewed the record and verified these findings, confirming that the documentation indicating clear speech was inaccurate in relation to the resident’s actual speech status.
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