Incomplete Medical Record Documentation for Resident with Urinary Symptoms
Penalty
Summary
The facility failed to ensure that medical records were complete and accurate for one resident reviewed for neglect. Specifically, the resident was admitted with a documented complaint of burning during urination, and a progress note indicated this symptom. An on-call physician's note showed that a urinalysis and urine culture were ordered due to dysuria. However, staff did not document that the provider was notified about the resident's symptoms, nor did they enter the orders for the urinalysis and urine culture into the electronic medical record (EMR). Interviews with staff, including an LPN, the DON, and a corporate nurse, confirmed that there was no documentation in the EMR regarding provider notification or the entry of the physician's orders. The on-call physician's note was only available as a scanned document, which staff would not routinely see, and there was no evidence that the required urine tests were ordered or collected as directed. Staff acknowledged that it was their responsibility to document provider contact, enter orders, and complete ordered tasks in the EMR, but these actions were not completed for this resident.