Failure to Maintain Complete and Accurate Medical Records
Penalty
Summary
The facility failed to maintain complete and accurate medical records in accordance with accepted professional standards for two residents. For one resident admitted with a diagnosis of Tinea Unguium, the medical record did not contain documentation of several podiatry visits, despite the resident exhibiting elongated, thickened toenails and dry, cracked skin upon observation. The missing podiatry notes were later obtained from the podiatrist's office but were not present in the resident's official medical record at the time of review. The Director of Nursing confirmed the absence of these records in the resident's file. For another resident admitted for rehabilitation following an orthopedic procedure, the medical record lacked documentation of an orthopedic follow-up appointment, including the findings and recommendations from that visit. The Director of Nursing confirmed that the consult report from the orthopedic follow-up was not included in the resident's medical record. These omissions demonstrate a failure to safeguard and maintain resident-identifiable information and medical records as required.