Failure to Maintain and Document MD/NP Visit Notes in Resident Medical Records
Penalty
Summary
Surveyors found that the facility failed to maintain complete, accurate, and readily accessible medical records for all residents reviewed. Specifically, for 13 residents, there was no documentation of routine or acute visits by medical doctors (MD) or nurse practitioners (NP) in either the electronic health record (EHR) or paper charts. This lack of documentation was discovered during a review of records and interviews with staff, who confirmed that visit notes were not regularly obtained or filed in the residents' records. Facility policies require licensed nurses to track physician visit due dates, remind physicians to document visits, and for the Director of Nursing or designee to conduct monthly audits for timeliness. Additionally, all assessments, observations, and services provided are to be documented in accordance with state law and facility policy. Despite these policies, staff interviews revealed inconsistent practices regarding access to and retrieval of MD/NP visit notes. Some staff had access to the EHR but did not check it regularly, while others lacked access entirely and relied on supervisors for information. Further interviews with the Nursing Supervisor, RNs, LPNs, the Nursing Home Administrator, and Medical Records staff indicated a lack of clarity and consistency in responsibility for obtaining and tracking MD/NP visit documentation. The Medical Records staff acknowledged that a comprehensive review had not been conducted recently, and that obtaining visit notes had not been consistently performed. As a result, the facility did not have the required MD/NP visit notes readily accessible in the health records for the residents reviewed.