Misfiled Dialysis Record Compromises Resident Privacy
Penalty
No penalty information released
The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.
Summary
The facility failed to maintain complete and accurate medical records for one of twenty-seven residents when a clinical document related to dialysis care for a resident who was dependent on dialysis was found in the electronic health record (EHR) of another resident who did not have a diagnosis requiring dialysis. Specifically, a document titled 'DIALYSIS CARE COMMUNICATION COORDINATION' for the resident dependent on dialysis was incorrectly filed in the EHR of a different resident. This error was confirmed by the Assistant Director of Nursing (ADON), who acknowledged that the clinical document was in the wrong resident's record and emphasized the importance of maintaining resident documents in the correct location to ensure privacy.