Incomplete and Disorganized Medical Records for Residents
Penalty
Summary
The facility failed to ensure that resident medical records were complete, accurate, readily accessible, and systematically organized for three of four sampled residents reviewed for transfer and discharge. For two residents with multiple hospital transfers, there was no documentation in their medical records regarding the details of the hospital encounters, including the resident's status, assessment, testing, treatment, or plan of care. Staff interviews confirmed that hospital records should be scanned into the electronic medical record to maintain completeness and accuracy, but this was not done for these residents. For another resident with severe cognitive impairment and a history of stroke, the medical record lacked documentation of the final events leading up to the resident's death, including who assessed the resident, determined the time of death, or who was notified of the passing. The only documentation present was a Record of Death form indicating the date and time of death and body release. Staff interviews confirmed the expectation that a progress note should be written to include the events regarding a resident's passing.