Failure to Maintain Accessible and Complete Medical Records
Penalty
Summary
The facility failed to maintain accessible and complete medical records for five residents, as required by accepted professional standards. Staff, including CNAs and LPNs, were unable to verify which fall prevention interventions had been implemented or completed for several residents because the electronic medical record (EMR) system did not have a centralized or easily accessible location for this information. This lack of organization in the EMR compromised staff's ability to deliver consistent care and monitor resident safety effectively. Additionally, the facility's binder intended for emergency use, which should document advanced directives and code status, was not up to date and did not include this information for multiple residents. Staff reported difficulty locating residents' code status and advanced directives in both the EMR and the physical binder, with some staff unaware of the binder's existence or location. The administrator confirmed that while the POLST forms were present in the EMR, they were not easily accessible, and the binder was not current, which could delay emergency care. There was no specific policy ensuring that medical records, including advanced directives, were easily accessible to staff.