Split Rock Rehabilitation and Health Care Center, a nursing home located in the Bronx, was cited in a 2010 Department of Health Deficiency Survey for failing to accurately maintain clinical records documenting care provided. The DOH noted several failures to comply with CFR 483.75(l)(1), which provides that clinical records for each resident must be, among other requirements, complete and accurate. One particular incident documented a resident being bathed and toileted during a five day period during which the resident was in a different hospital, thus not present in the nursing home.
Although documenting care while a resident is not present in a facility arguably has no direct adverse effect on the resident, it underlies a potentially serious issue highlighted by several other incidents in the same DOH report. Failure to completely and accurately document patient care can have dire consequences for the resident. In two other occurrences at Split Rock, patient notes were either incomplete or unable to be found. Accurate record-keeping ensures both that patients are cared for, and that nurses and doctors a communicate about this care rendered. Without these records to document, among other things, bathing, toileting, and medicine, nurses are unable to accurately track the care provided to the residents in their charge. This can have serious health consequences for elderly patients, such as bedsores and malnutrition.
The DOH report, which can be found here, documents no actual harm, but the potential for more than minimal harm.