Incomplete Physician Documentation in EMR
Penalty
Summary
The facility failed to maintain a complete and accurate medical record for one resident, as required by its own Charting and Documentation policy and accepted professional standards. Specifically, the physician's visit progress notes for the resident were not maintained in the electronic medical record (EMR) and were not readily accessible. The last physician's visit progress note in the EMR was from April 2024, despite the resident being seen by the physician on multiple occasions after that date. The physician's notes for these subsequent visits were not uploaded to the EMR, resulting in incomplete documentation. This deficiency occurred after the facility eliminated its medical records department and assigned the responsibility of scanning medical records into the EMR to the receptionist. Additionally, the physician's access to the EMR was revoked when he ceased to be the facility's medical director, even though he continued to serve as the resident's primary provider. The physician's EMR access was not reinstated until the time of the survey, which contributed to the lack of timely and complete documentation in the resident's medical record. The resident involved had multiple complex medical conditions, including multiple sclerosis, generalized muscle weakness, and dementia, and was dependent on staff for most activities of daily living.