Failure to Maintain and Document Medical Records Following Outside Consultation
Penalty
Summary
The facility failed to ensure that a resident who attended an outside cardiology consultation returned with progress notes and care instructions that were available in the resident's medical record. The resident, who had end stage renal disease and moderate cognitive impairment, was scheduled for a micro laryngoscopy for vocal cord lesion removal. Physician's orders indicated the need for a cardiology clearance prior to surgery, and the resident had an appointment with a cardiologist. However, upon review, there was no documentation in the medical record of the consultation note or care instructions following the cardiology appointment. Interviews with facility staff revealed that the Social Services Director was initially unaware if the resident attended the appointment and only later obtained the cardiology notes after contacting the cardiologist's office. The Director of Nursing, upon not finding the cardiology note in the medical record, assumed the appointment had not occurred and scheduled another cardiology appointment, resulting in a delay in the planned surgery. Facility policy required that orders and follow-up appointments be documented in the electronic record and that medical records be maintained appropriately, but these procedures were not followed in this instance.