Incomplete Medical Records Due to Missing Physician Signatures
Penalty
Summary
The facility failed to maintain complete and accurately documented medical records for two residents, as required by federal regulations and facility policy. For one resident with a history of seizures, bipolar disorder, diabetes mellitus, and dementia, the informed consent (IC) form for a prescribed medication was not signed by the physician. The IC was only signed by the resident's responsible party and a licensed nurse, despite the facility's policy stating that the physician or prescriber must sign the form after explaining the necessary information to the resident or their representative. Both the Medical Records Director (MDR) and a registered nurse confirmed during interviews that the physician's signature was missing and acknowledged that it was their responsibility to ensure the form was properly completed. For another resident with diagnoses including psychosis, muscle weakness, and dementia, the attending physician did not review and sign the resident's Order Summary on a monthly basis, as required. Record reviews showed that the Order Summary reports for several months were unsigned by the physician. Both the MDR and a registered nurse confirmed that the physician should have signed the Order Summary each month to indicate approval of the resident's care orders. The Director of Nursing (DON) also stated that the MDR was responsible for ensuring timely audits and complete medical records, and that the physician should have reviewed and signed the Order Summary during follow-up visits, at least every 60 days. Facility policies reviewed during the investigation reinforced the requirements for complete, accurate, and objective documentation in the medical record, as well as the physician's responsibility to review and document the resident's total program of care at each visit. The failure to obtain the necessary physician signatures on both the informed consent form and the monthly Order Summaries resulted in incomplete and potentially inaccurate medical records for the two residents involved.
Plan Of Correction
F-842 Immediate corrective action: On 04/27/2025, the Director of Nurses assessed the resident for use of Depakote. Resident has been receiving Depakote as ordered by MD and as it was verified by nurses with Resident Representative. Action taken to identify all other residents: On 04/27/2025, other residents' consents were reviewed by Medical Records, but no other residents were affected by the same deficient practice. Process and action taken to ensure the deficient practice does not reoccur: On 04/27/2025, the Director of Nurses conducted an in-service with the Medical Record Director regarding the importance of signing consents timely that were verbally obtained from resident/resident representative by MD and verified by nurses. Monitoring performance to ensure that correction is achieved and sustained: The medical records will audit charts every month for 3 months to ensure that all informed consents are properly signed by MD. As part of the facility QAPI program, the DON will present a recapitulation of the Medical Record Director findings to the QAA committee monthly for the next month for review and action as indicated. The DON will monitor compliance through review of monthly reports by the Medical Record Director. Immediate Corrective Action: On 04/27/2025, the Director of Nurses reviewed the resident's medication summary: DON called and reviewed all medications with the Primary Care provider. Received order to continue all medications as ordered. No changes at this time needed. Action taken to identify all other residents: On 04/27/2025, other residents' order summaries were reviewed by Medical Records, and no other residents were affected by the same deficient practice. On 04/27/2025, the Director of Nurses conducted an in-service with the Medical Record Director regarding the importance of doctors signing order summaries in a timely manner. Monitoring performance to ensure that correction is achieved and sustained: The Medical Records will audit charts every month for 3 months to ensure that all ordered summaries are properly and timely signed by MD. As part of the facility CQI program, the DON will present a recapitulation of the Medical Record Director findings to the QAA committee monthly for the next three months for review and action as indicated. The DON will monitor compliance through review of monthly reports by the Medical Record Director.