Physician Progress Notes Missing from EMR
Penalty
Summary
The facility failed to maintain complete and accessible medical records for a resident, specifically by not ensuring that physician's progress notes were available in the electronic medical record (EMR) after a certain date. Record review showed that there were no physician's progress notes in the resident's EMR after 1/15/25, making these records unavailable for review during the survey. The resident in question was over 65 years old, had diagnoses including high blood pressure, diabetes mellitus, and Alzheimer's disease, and was assessed as severely cognitively impaired and dependent on staff for all activities of daily living. During staff interviews, the DON confirmed the absence of physician's progress notes in the EMR after the specified date. It was explained that the previous physician documented in a system separate from the facility's EMR, and records could only be obtained by special request. The facility had recently changed physician providers and was in the process of ensuring that documentation would be available in the EMR moving forward. However, at the time of the survey, the required physician documentation was not present in the resident's health record.