Incomplete Medical Record Documentation and Accessibility
Penalty
Summary
The facility failed to ensure that medical records for multiple residents were complete, accurately documented, and readily accessible, as required by professional standards and facility policy. For one resident receiving a Restorative Nursing Aide (RNA) feeding program, the RNA flow sheets for two consecutive months were incomplete, with missing documentation of the provision of the feeding program and the initials of the RNA responsible for care. Interviews with staff confirmed that the RNA feeding program was provided daily, but the required documentation was not consistently completed, leaving blank spaces and missing signatures on the flow sheets. Another resident's record lacked documentation of Interdisciplinary Team (IDT) meeting attendance. Although IDT meetings were held, there was no record of who attended, including whether the resident or their representative participated. The Social Services Director and Director of Nursing acknowledged that the facility did not have a consistent process for tracking IDT attendance, and the required sign-in sheets or documentation were missing from the resident's record. Facility policy required prompt, complete, and accurate documentation of all care planning meetings and attendance. A third resident's medical record did not contain optometrist and ophthalmologist visit notes, despite the resident having significant vision-related diagnoses and recent eye care consultations. Nursing staff confirmed that these consult reports were not filed in the resident's chart, which prevented timely follow-up with the primary physician regarding the specialist's recommendations. The Director of Nursing stated that consult notes should be promptly filed and followed up to ensure appropriate care. Facility policy required that all direct services and observations be documented in the resident's record as soon as possible.