Incomplete Medical Records for Residents
Penalty
Summary
The facility failed to ensure that medical records for three residents were complete and accurately documented, as required by their policy. Resident R17, who was admitted with chronic obstructive pulmonary disease, obstructive sleep apnea, and respiratory failure, was transferred to the hospital multiple times for respiratory distress. However, the facility did not include hospital discharge summaries from these stays in the resident's clinical record. This was confirmed by the Nursing Home Administrator during an interview. Resident R34, admitted with high blood pressure, diabetes, and pain, had physician's orders for several blood tests, but the facility failed to provide hospital records or lab results until requested. Similarly, Resident R66, admitted with high blood pressure, depression, and cerebral infarction, had a physician's order for a diagnostic mammogram, but the facility did not have the mammogram results on file until they were faxed from the hospital. The Director of Nursing confirmed the incomplete documentation for Resident R66.
Plan Of Correction
R66 test results were received on 12/19/24. R17 and R34 appointments and medical records were audited and appointments made as needed. Other residents who have had procedures or tests at the hospital within a lookback of 3 months will be audited for documentation. DON or designee will audit residents who have had procedures or tests at an outside location to ensure facility completely and accurately documents as appropriate weekly for 4 weeks then monthly for 2 months. Medical Records clerk will be educated on the expectation of ensuring facility completely and accurately documents external procedures and tests by DON or designee. Audit results will be reviewed through the monthly QAPI process/meeting.