Incomplete Medical Records Due to System Change
Penalty
Summary
The facility failed to develop and implement an effective quality assurance plan capable of identifying and correcting ongoing quality deficiencies related to maintaining complete and accurate medical records. A review of the facility's Quality Assurance and Performance Improvement (QAPI) program policy revealed that its purpose is to proactively improve care delivery and engage stakeholders in maximizing quality of life and care. However, the facility's QAPI activities did not address the issue of incomplete medical records following a change in electronic medical record systems. The deficiency was highlighted by the incomplete transfer of a care plan for a resident diagnosed with Dementia with Lewy Bodies. The resident's care plan, initiated in July 2022, was not fully transferred to the new electronic system implemented in April 2024. During interviews, the Director of Nursing (DON) confirmed the incomplete status of the resident's care plan and acknowledged that the facility did not know how many residents had complete medical records. The ongoing issue with medical record transfers was not included in the facility's quality assurance program, indicating a failure to identify and address this deficiency.
Plan Of Correction
Resident 19's clinical record is complete. To identify other residents that have the potential to be affected, the facility will complete an audit to ensure all medical records are complete. To prevent re-occurrence, the contracted medical records consultant will educate medical records personnel on complete chart requirements. To monitor and maintain compliance, the medical records/designee will audit new admissions weekly for 4 weeks and monthly for 2 months to ensure records are complete. All results will be brought to the QAPI committee.