Incomplete and Delayed Physician Documentation in Resident Medical Record
Penalty
Summary
The facility failed to ensure that clinical records were complete and accurately documented for one resident. According to facility policy, attending physicians are required to provide timely and pertinent documentation, including a progress note at each visit, which should be placed in the medical record within a week. However, review of the clinical record for a resident admitted with hypertension and bilateral fibula fractures revealed no physician progress notes since admission as of the date of review. Interviews with the DON and NHA confirmed that the process for receiving, printing, and placing physician notes on resident charts was unclear, and that the physician responsible for the resident was not timely in providing documentation. Only three progress notes were eventually obtained after the DON contacted the physician, and there was no evidence of additional notes or confirmation of when the resident was last seen by the physician. Both the DON and NHA acknowledged that physician progress notes were not consistently available within the expected timeframe outlined in facility policy.