Care Plans Not Accessible in Electronic Medical Records
Penalty
Summary
The facility failed to maintain complete and accurately documented medical records in accordance with accepted professional standards for two residents. Specifically, care plans for these residents were not accessible in their current active electronic medical records. One resident, a female with muscle weakness, atrophy, lack of coordination, and cognitive communication deficit, had a moderate cognitive impairment as indicated by a BIMS score of 10 out of 15. Another resident, a female with hypertension, atrial fibrillation, and osteoarthritis of the hip, had a severe cognitive impairment with a BIMS score of 7 out of 15. Despite their needs, neither resident had a care plan available in the current electronic system. Interviews with facility staff revealed that the transition from the former electronic medical record system to the current one (PCC) resulted in incomplete transfer of care plans. The MDS Coordinator acknowledged that not all care plans had been entered into the new system and that staff were instructed to request care plans or MDS assessments from her if needed. However, there was no specific training for staff to know they could contact the MDS nurse or administration at any time for this information. The facility's policy required comprehensive assessments to be maintained in the resident's active record, but this was not followed for the affected residents.