Incomplete Medical Records for Two Residents
Penalty
Summary
The facility failed to ensure that medical records for two residents were complete and accurately documented. Resident R59 was admitted to the facility and passed away on December 2, 2024. However, the 'Interdisciplinary Discharge Summary' and 'Disposition of Medications' forms dated December 2, 2024, were not completed. Similarly, Resident R61 was admitted and discharged from the facility, but the same forms dated November 19, 2024, were also incomplete. During an interview, the Director of Nursing confirmed these findings, acknowledging that the facility did not maintain complete and accurate medical records for these residents. The facility's policy requires that clinical records be completed within 30 days of a resident's discharge, which was not adhered to in these cases.
Plan Of Correction
R 59 and R 61 have been discharged so we cannot update the discharge summary and disposition of medication. Like residents can be affected. Medical records and licensed staff have been educated by the director of nursing or designee on discharge medical records to include discharge summary and disposition of medications. Medical records will audit 5 discharge records a week for 4 weeks to ensure that discharge summaries and disposition of medications are completed. Findings will be reported to the quality assurance and process improvement committee meetings.