Failure to Document Clinic Appointment Arrangements and Outcomes
Penalty
Summary
The facility failed to maintain complete and accurate medical records for one resident by not documenting the arrangements for a scheduled clinic appointment and the outcome of that appointment. The resident, who had a history of cerebral infarction, hemiplegia, heart failure, asthma, and depression, was noted to have moderately impaired cognitive functioning and was dependent on staff for certain activities of daily living. A physician's order indicated a scheduled follow-up appointment with a pulmonologist, including specific instructions for preparation and required documentation to accompany the resident. Upon review, it was found that while the appointment was noted in the resident's records, there was no documentation regarding the transportation arrangements made for the appointment or whether the appointment was completed. The Social Services Director confirmed the lack of documentation for both the transportation and the appointment outcome. The Director of Nursing stated that each discipline is responsible for updating resident records and that such documentation should have been present. Facility policy also requires all disciplines to document relevant resident progress and events in the medical record according to professional standards.