Missing EKG Reports in Resident's Medical Records
Summary
The facility failed to maintain complete medical records for one resident, identified as Resident 14, by not including signed and dated reports of diagnostic services. Resident 14, who had a complex medical history including cerebral infarction, hemiplegia, cognitive communication deficit, and other conditions, was ordered a 12 lead EKG for monitoring over two days. However, the EKG reports were not found in the resident's medical records. During an interview, the Director of Nursing (DON) acknowledged that the EKG report was obtained but was sent to the provider instead of being filed in the facility's records.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A resident with kidney failure, thrombocytopenia, and chronic myelomonocytic leukemia had a STAT EKG ordered for a low and fluctuating HR with nausea, but the EKG report was not found in the medical record. The RNC stated the facility had to call and obtain the results.
A resident with multiple diagnoses including dementia, atrial fibrillation, dysphagia, and chronic pain had a productive cough and bilateral crackles, and the MD ordered a STAT CXR after being notified. Record review found no signed and dated CXR report in the resident record. The DON stated the result was reviewed with the nurse and was located in a group chat, but it was not included in the medical record, and the facility needed to work on its weekend process.
A resident with paroxysmal atrial fibrillation, repeated falls, and unspecified tremor had a head CT ordered for increased confusion and a high INR, and was transported to the hospital for the test. Surveyors found the CT results were not filed in the medical record, and the DON stated she had to request the report from the hospital because it was missing from the chart.
A resident with multiple complex diagnoses had a STAT KUB x-ray ordered and performed due to abdominal symptoms, but the signed and dated x-ray report was not filed in the clinical record. Staff interviews revealed inconsistencies in the process for handling and filing diagnostic results, resulting in the required documentation being unavailable in the resident's chart.
Missing Diagnostic and Lab Results in Resident Records: The facility failed to file lab and diagnostic reports in the clinical records for two residents. One resident with cancer-related diagnoses had a CBC/CMP result missing from the EMR, and another resident with DM, CHF, CAD, and other chronic conditions had multiple lab results not uploaded to the EMR despite active orders and care plan directions to monitor labs and diagnostic work.
A resident who experienced increased heart rate and low-grade fever had a stat EKG ordered by a nurse practitioner. Although an LPN reported that the EKG was performed, the signed and dated EKG report was not filed in the resident's medical record, as confirmed by a review of the electronic record and staff interview.
Missing EKG Report in Resident Record
Penalty
Summary
The facility failed to keep signed and dated reports of diagnostic services in the resident record. For Resident 99, who was admitted and later readmitted with diagnoses including unspecified kidney failure, thrombocytopenia, and chronic myelomonocytic leukemia, a STAT EKG was ordered on 6/1/26 due to a heart rate ranging from 37 to 54 and nausea. During record review, the EKG report was not located in the resident's medical record. In an interview on 6/24/26, the Regional Nurse Consultant stated the EKG was not in the resident's medical record and that the facility had to call and obtain the results.
Missing Chest X-Ray Report in Resident Record
Penalty
Summary
Keep signed and dated reports of x-rays and other diagnostic services in the resident record was not met for 1 of 40 sampled residents. Resident 6 was admitted and re-admitted with diagnoses including contracture of both hands, dysphagia, hypothyroidism, dementia, atrial fibrillation, pain, hypertension, chronic pain, deformity of the left lower leg, peripheral vascular disease, and idiopathic neuropathy. On 1/10/26, a progress note documented that the resident had a productive cough and bilateral crackles, the MD was notified, and a STAT chest x-ray was ordered. During record review, no documentation of the chest x-ray was found in the resident's medical record. The DON stated the results came in on Saturday and were reviewed by the MD with the nurse, that the result was located in a group chat, and that she did not know why it was not included in the resident's medical record. The DON also stated the facility needed to work on its weekend process.
Missing CT Report in Resident Record
Penalty
Summary
Keep signed and dated reports of x-rays and other diagnostic services in the resident's record was cited after surveyors found that one of 25 sampled residents did not have radiologic reports filed in the clinical record. Resident 14 was admitted with diagnoses including paroxysmal atrial fibrillation, repeated falls, and unspecified tremor. The resident's record showed that on 8/18/25 a nurse documented that the provider ordered a head CT due to increased confusion and a high INR, and that the resident was transported to and from the hospital for the appointment. However, the head CT results could not be located in the medical record. During interview, the DON stated she had to request the head CT results from the hospital because they were not in the record, and stated that radiology results should be uploaded into the medical record under the miscellaneous tab.
Failure to File Signed and Dated Diagnostic Report in Resident Record
Penalty
Summary
A deficiency was identified when the facility failed to file a signed and dated report of a radiological diagnostic service in a resident's clinical record. The resident, who had a history of traumatic subdural hemorrhage with loss of consciousness, quadriplegia, spinal stenosis, and post-traumatic stress disorder, was admitted to the facility and later had a physician's order for an immediate (STAT) Kidney, Ureter, and Bladder (KUB) x-ray due to abdominal symptoms. Although nursing notes referenced the x-ray and its impression, the actual documentation of the x-ray results could not be located in the resident's medical record during the review period. Interviews with multiple staff members, including LPNs, the Regional Compliance Nurse, the DON, and the Administrator, revealed that the process for handling x-ray results involved receiving faxed reports from the x-ray company, notifying the physician, and distributing copies to various offices before forwarding the results to medical records for scanning and attachment to the resident's chart. However, there was a lack of clarity and consistency in the process, and the KUB x-ray result for the resident in question was not found in the clinical record as required.
Missing Diagnostic and Lab Results in Resident Records
Penalty
Summary
The facility failed to file signed and dated reports of x-rays and other diagnostic services in the clinical records for 2 of 8 residents reviewed. Resident #3, an older male with diagnoses including cerebral infarction, dysphagia, acute myeloblastic leukemia not having achieved remission, multiple myeloma, and immunodeficiency, had an active order for CBC and CMP related to multiple myeloma dated 09/14/2025, but the lab result was not uploaded to his electronic medical record when reviewed on 10/08/2025. His care plan included chemotherapy treatment and education on the importance of routine laboratory monitoring. Resident #4, an older male with diagnoses including muscle weakness, diabetes mellitus, hyperlipidemia, hypertension, atherosclerotic heart disease, atrial fibrillation, and heart failure, had multiple active lab orders related to diabetes, a sacral ulcer, and CHF. Record review on 10/07/2025 showed that lab results ordered on 02/08/2025, 03/16/2025, 03/18/2025, and 04/11/2025 were not uploaded to his electronic medical record. His care plan included monitoring lab and diagnostic work as ordered, monitoring cholesterol levels, and fasting serum blood sugar as ordered by the doctor.
Failure to File Signed and Dated EKG Report in Medical Record
Penalty
Summary
The facility failed to file a signed and dated EKG report in the medical record for one resident. The resident had experienced an increased heart rate and low-grade fever, prompting a nurse to consult with a nurse practitioner, who ordered a stat EKG, chest x-ray, and urinalysis. Although the EKG was reportedly performed later that day, a review of the resident's medical record did not contain any evidence of the EKG being completed or filed, as confirmed by both the electronic results tab and the miscellaneous section of the record. During an interview, the LPN explained that the EKG should have been downloaded into the medical record but was not, resulting in the absence of the required documentation.
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