Inaccurate Documentation of Diagnostic Test Results
Penalty
Summary
The facility failed to maintain complete and accurate clinical records for a resident who was ordered a venous doppler scan to the left lower extremity due to edema. The resident, who had a history of hemiplegia, hemiparesis following stroke, breast and bone cancer, and heart failure, was noted to have bilateral lower extremity edema. Although a physician's order was placed for a doppler scan, and subsequent documentation indicated the test was negative, the resident later reported not having received the scan. Upon review, the facility administrator confirmed that the doppler scan was never performed and that the documentation stating otherwise was charted in error. This resulted in inaccurate documentation of diagnostic testing in the resident's medical record.