Failure to Document Physician Visit in Resident Medical Record
Penalty
Summary
Facility staff failed to maintain a complete and accurate medical record for one resident when they did not document the resident's visit to a urologist in the medical record. The resident, who had diagnoses including urinary tract infection, type 2 diabetes mellitus, and hypertension, was admitted and later readmitted to the facility. According to the Minimum Data Set, the resident had no cognitive impairment and was dependent on staff for lower body dressing, bathing, and toileting hygiene. The resident's granddaughter confirmed accompanying the resident to a urologist appointment, but there was no documentation of this visit in the resident's progress notes. During a review of the facility's policy and procedure on charting and documentation, it was found that physician visits and orders are required to be documented in the resident's record. The Director of Nursing confirmed that the appointment was not documented as required. This omission resulted in the resident's medical record lacking a summary of the physician visit, leading to incomplete information in the resident's chart.