Failure to Maintain Complete and Accurate Medical Records
Penalty
Summary
The facility failed to maintain a complete and accurate medical record for one resident. The resident's face sheet did not document any diagnosis of wounds or skin issues, including maggots, and her Minimum Data Set indicated she was alert. The facility's LPN reported that the facility podiatrist assessed the resident, but there was no documentation of the podiatrist's progress notes in the resident's electronic medical record. The administrator confirmed that the podiatrist does not share or send his progress notes to the facility and never has. The podiatrist stated that his office typically sends progress notes to the facility within a few days after assessments and was unaware that the facility was not receiving or uploading these notes. The facility's policy requires all observations and services performed to be documented in the resident's clinical record.