Missing Recapitulation of Stay in Resident Records
Penalty
Summary
The facility failed to include a recapitulation of stay in the medical records of two residents, CR81 and CR83, as required by regulations. Resident CR81 was admitted on 10/29/22 with diagnoses including metabolic encephalopathy, bactremia, urinary tract infection, and severe protein calorie malnutrition. Progress notes indicated that Resident CR81 ceased to breathe on 11/15/24, yet the clinical record lacked a summary of the resident's stay and course of treatment at the facility. Similarly, Resident CR83 was admitted on 4/10/24 with conditions such as diabetic ulcers, end-stage renal disease, Type 2 Diabetes, and peripheral vascular disease. A progress note dated 11/10/24 indicated that Resident CR83 was transported to an acute hospital for evaluation and did not return to the facility. However, the clinical record for Resident CR83 also lacked a recapitulation of the resident's stay. The Regional Clinical Consultant confirmed the absence of these summaries during an interview.
Plan Of Correction
Resident # 81 and # 83 recapitulation was completed. Residents discharged and or ceased to breathe within the last 15 days will be reviewed for recapitulation of stay and will be completed. The Intradisciplinary team will be educated on the recapitulation of stay that is to be completed for any discharged or ceased to breathe by the Administrator. An audit will be conducted on residents that all discharged or ceased to breathe weekly for 4 weeks then monthly by the Administrator to ensure a recapitulation of stay is completed. Findings will be reported to the Quality Assurance Performance Improvement committee for review and recommendations.