Incomplete Medical Record Documentation for Hospitalized Resident
Penalty
Summary
The facility failed to maintain a complete, accurately documented, and readily accessible medical record for a resident who was reviewed for documentation. The resident was admitted to the facility and subsequently sent to the hospital due to confusion, weakness, and distress. Upon return from the hospital, the resident's electronic health record (EHR) was missing key documents, including a provider visit note from the day the resident was sent to the hospital, as well as the hospital discharge summary and physician history and physical (H&P) from the hospitalization period. Interviews with facility staff revealed that while there was a process for uploading provider notes and hospital documents into the EHR, there was a lack of tracking for non-routine provider visits and some hospital documents. The health unit coordinator confirmed that the missing documents were not present in the EHR and should have been uploaded, and the director of nursing acknowledged that the resident's medical record was incomplete and not accurate at the time of review. Facility policy required that such documentation be included in the resident's legal health record.