Incomplete Medical Record Documentation for PT Evaluation
Penalty
Summary
Facility staff failed to maintain a complete and accurate medical record for a resident. A review of the resident's electronic medical record showed a physician order for physical therapy (PT) to evaluate wheelchair and positioning, but there was no documentation available to confirm whether the evaluation occurred. During interviews, the Director of PT was unable to confirm or deny if the evaluations took place due to the absence of information in the electronic medical record. The Director of Nursing also confirmed that the medical record was not maintained in its most complete form for the resident. This deficiency was identified through medical record review and staff interviews, which revealed that required documentation related to a physician-ordered PT evaluation was missing from the resident's record.