Failure to Maintain Complete Laboratory Records in Resident Chart
Penalty
Summary
A deficiency was identified when the facility failed to maintain complete, dated laboratory records in a resident's clinical record. Specifically, for one resident with multiple complex diagnoses, including benign neoplasm of the brain, chronic respiratory failure with hypoxia, heart failure, chronic obstructive pulmonary disease, and epilepsy, laboratory results for serum phenytoin and phenobarbital were not found in the electronic medical record. The pharmacy had recommended these labs due to the resident's medication regimen, and the attending physician had agreed to the orders. However, a review of the resident's chart revealed that no such lab results were present for the past six months, and there were no routine orders in place for these labs to be drawn. Interviews with facility staff revealed that diagnostic results were sent to medical records to be scanned and uploaded into the electronic medical record. The DON stated that this process typically took about a week, while the medical records staff indicated that she aimed to upload records the same day she received them and then destroyed the originals. Despite these procedures, the required laboratory reports for the resident were not located in the electronic medical record, resulting in incomplete documentation.