Missing Diagnostic Test Results in Medical Record
Penalty
Summary
The facility failed to maintain complete and accurate medical records in accordance with accepted professional standards for one resident reviewed during a complaint survey. Specifically, a resident admitted with a diagnosis including bladder neck obstruction had a physician order for a cystoscopy. Upon review of both electronic and paper medical records, the results of the cystoscopy were not found. This omission was confirmed during an interview with the Administrator, who acknowledged that the medical record did not contain the required cystoscopy results. The deficiency was identified through medical record review and staff interview, demonstrating that the facility did not ensure all relevant diagnostic results were included in the resident's official medical record.