Incomplete Medical Records and Missing Dialysis Communication Documentation
Penalty
Summary
Facility staff failed to maintain complete and accurate medical records for a resident who experienced a leg injury during transport to a dialysis center. The incident began when the resident, who had a history of advanced osteoporosis and a prior fracture in the same leg, complained of leg pain and swelling upon arrival at the dialysis center. The dialysis nurse documented the resident's complaints, vital signs, and communication with the facility nurse on a flow sheet, which was sent back to the facility. However, upon review, the communication flow sheet for the relevant date was missing the dialysis nurse's written notes and signature. The facility's records included an incident report and subsequent medical interventions, such as Tylenol administration, notification of the CRNP, diagnostic imaging, and pain management, but lacked the original documentation from the dialysis center. Interviews with facility staff, the dialysis nurse, and the Director of Nursing revealed inconsistencies and gaps in the documentation process. The Director of Nursing stated that the previous Administrator may have taken investigation records with them, and the dialysis communication flow sheet for the incident date was found to be incomplete. Staff interviewed were unaware of the missing documentation, and the communication logs provided did not contain the dialysis nurse's original notes. This failure to safeguard and maintain complete resident medical records, specifically the communication flow sheets with the dialysis center, constituted the identified deficiency.