Failure to Maintain Complete and Accurate Medical Records
Penalty
Summary
The facility failed to maintain complete and accurate medical records in accordance with accepted professional standards for one resident. Medical record review revealed that the resident, who had been admitted in 2010, did not have documentation of podiatry visits after a specific date, despite having received podiatry care on multiple occasions. During the survey, staff were unable to locate records of podiatry visits that occurred after the last documented date. It was later confirmed through interviews and provision of evaluation forms that several podiatry visits had taken place, but these records had not been uploaded into the resident's medical record due to confusion following a change in medical records staff. The deficiency was identified when the surveyor could not find documentation of the podiatry visits until after intervention.