Incomplete and Inaccurate Medical Record Documentation
Penalty
Summary
The facility failed to maintain complete and accurate medical records for multiple residents, as required by its own policies and professional standards. For several residents, provider progress notes were not uploaded into the electronic medical record (EMR), making them inaccessible to floor nurses and not part of the official resident record. Specifically, provider notes for four residents were only available through a separate electronic health record system accessible by nurse managers, not by floor staff. Additionally, an incident involving a resident's right leg injury was documented in an incident report but not in the resident's EMR, and the related provider note was also missing from the EMR. In another case, a resident eloped from the facility, but the incident was not documented in the resident's medical record, and required notifications and procedures outlined in the facility's missing resident policy were not followed. The LPN involved did not document the elopement or the steps taken after the resident's return, and the administrator was unaware of the incident until after it occurred. The facility's policy requires thorough documentation and specific actions in the event of a missing resident, but these were not completed or recorded in the medical record.