Failure to Maintain Readily Accessible Medical Records
Penalty
Summary
The facility failed to ensure that medical records for a resident were readily accessible, specifically by not having the resident's Orthopedic consultation note from a follow-up appointment available in the electronic medical record. The resident, who had a history of right-sided hemiplegia and hemiparesis following a cerebral infarction, aphasia, and osteoarthritis of the left hip and knee, had a physician's order for an Orthopedic consult due to left hip and knee pain. Progress notes indicated that the resident attended the Orthopedic appointment and received a recommendation for a cortisone injection, but the actual consultation note documenting this visit was missing from the electronic records. During the review, both a registered nurse and the DON confirmed that they were unable to locate the Orthopedic note in the electronic system, which was being used as the facility transitioned to paperless charting. The absence of this record meant that staff could not verify the most current recommendations for the resident's care. The facility's policy required that all current medical records be maintained and safeguarded, but the Orthopedic note was not accessible as required.