Penalty

Fine: $39,49034 days payment denial

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to maintain accurate and up-to-date medical records for several residents, as evidenced by multiple discrepancies and omissions in documentation. For one resident, the care plan sign-in sheet and face sheet incorrectly listed a family member as the power of attorney for health care decisions, despite documentation showing the resident had decision-making capacity and the power of attorney was only for financial matters. The care conference invitation was also misaddressed, and the error was only identified after surveyor intervention. Another resident's peripherally inserted central catheter (PICC) dressing was observed without a date or time, and there was no documentation of a dressing change in the medical record, even though the change was reportedly performed. Additionally, two residents' smoking status assessments and care plans were not updated to reflect their current abilities and preferences. One resident was listed as an independent smoker on the facility's list, but the medical record and care plan still indicated the need for supervision, while another resident's assessment failed to indicate they smoked, despite care planning for independent smoking. A further deficiency was noted in the documentation of a resident's fall. Progress notes contained conflicting dates and times regarding when the fall occurred, with some notes indicating different days and times for the same incident. Staff confirmed that only one fall had occurred, but the medical record did not accurately reflect this, leading to confusion and inconsistency in the resident's documentation.