Failure to Maintain Complete and Accessible Medical Records
Penalty
Summary
The facility failed to maintain complete, accurately documented, and readily accessible medical records for two residents. For both residents, their electronic health records (EHRs) did not contain any primary care provider visit notes from the time of their current admissions. The absence of these notes was confirmed during interviews with the director of nursing (DON), who acknowledged that the records were incomplete and did not meet expectations for accuracy and completeness. The missing provider notes were later retrieved from an external medical records system, revealing multiple visits that had not been uploaded into the facility's EHR. Interviews with facility staff, including the DON and the administrator, confirmed that provider notes are expected to be uploaded into the EHRs to ensure staff have access to complete resident information. The facility's own policy requires objective, accurate, timely, and clinically complete documentation in the medical record, including provider notes. However, the process for uploading these notes was not followed, resulting in incomplete records for the two residents reviewed.