Failure to Maintain Complete Physician Progress Notes in Medical Records
Penalty
Summary
The facility failed to maintain complete medical records by not ensuring that physician progress notes were written, signed, and dated during routine visits for four residents. Specifically, the medical records for these residents did not contain the required physician progress notes for their respective visits, despite having order summary reports signed by the physicians. The residents involved had various diagnoses, including atrial fibrillation, major depressive disorder, morbid obesity, lymphedema, cerebral palsy, epilepsy, Alzheimer's disease, type 2 diabetes, dementia, hypertension, insomnia, weakness, and osteoarthritis. The absence of these progress notes was identified through document review and interviews. During interviews, an LPN responsible for medical records explained that when physicians made rounds, she provided a list of residents needing evaluation and waited for the completed progress notes to be returned for scanning into the medical record. However, in some cases, such as when a physician resigned from their clinic, the notes were not entered into the record in a timely manner. The LPN stated that reminders to physicians about missing notes were given verbally but not documented, and the issue was not formally reported to administration. The administrator confirmed awareness of some missing documentation but was unaware of the extent or duration of the problem. Facility policy required physicians to review care and document progress notes at each visit, which was not consistently followed.