Incomplete Medical Record Documentation and Missing X-ray Results
Penalty
Summary
The facility failed to ensure that the medical records for a resident were complete and that the x-ray results were accessible and properly filed. Specifically, a physician ordered a stat x-ray of the resident's left leg and foot to evaluate pain and swelling, but the results were not available in the resident's medical record. There was no documentation of communication with the physician regarding the x-ray results, nor any evidence of follow-up with the x-ray provider. During a review, a nurse confirmed that the medical records were incomplete and that if documentation was missing, it was considered not to have occurred. The Director of Nursing stated that she had received the x-ray results and given them to a licensed nurse, but could not explain why the results were not accessible in the medical record and could not provide documentation that the results were reported to the physician. The facility's policies require that records be complete, accessible, and filed in a manner that allows for easy retrieval, and that staff document and report results of diagnostic tests to the physician. The failure to maintain complete and accessible records was observed during interviews and record reviews.