Incomplete Medical Records: Missing Immunization Documentation
Penalty
Summary
Surveyors determined that the facility failed to maintain complete and accurately documented medical records for four out of twenty-four sampled residents. Specifically, the immunization histories for these residents, who had various diagnoses including dementia, osteoporosis, macular degeneration, chronic pain, congestive heart failure, chronic kidney disease, morbid obesity, anxiety, type II diabetes, hyperkalemia, and neuropathy, were not found in their medical records. During interviews, the Administrator was unable to identify where the immunization records were stored if not in the medical record, and the DON stated that the records were kept in a pharmacy file in her office rather than in the residents' medical records. The DON also expressed uncertainty about what would happen if the immunization information was needed and not available in the medical record.