Failure to File Signed and Dated EKG Report in Medical Record
Penalty
No penalty information released
The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.
Summary
The facility failed to file a signed and dated EKG report in the medical record for one resident. The resident had experienced an increased heart rate and low-grade fever, prompting a nurse to consult with a nurse practitioner, who ordered a stat EKG, chest x-ray, and urinalysis. Although the EKG was reportedly performed later that day, a review of the resident's medical record did not contain any evidence of the EKG being completed or filed, as confirmed by both the electronic results tab and the miscellaneous section of the record. During an interview, the LPN explained that the EKG should have been downloaded into the medical record but was not, resulting in the absence of the required documentation.