Physician Progress Notes Not Maintained in Facility EMR
Penalty
Summary
The facility failed to maintain physicians' progress notes in the electronic medical record (EMR) for a resident with multiple complex medical conditions, including a history of stroke, left-sided paralysis, atrial fibrillation, epilepsy, diabetes mellitus, high blood pressure, depression, chronic pain, and mild intellectual disabilities. The resident was dependent on staff for activities of daily living and had moderate cognitive impairment. A review of the resident's records revealed that there were no physicians' progress notes available in the EMR for a period spanning over nine months. Interviews with the DON confirmed that the physician documented evaluations and progress notes in a separate health record system not maintained by the facility. As a result, if nursing or other healthcare providers required access to these records, they were not immediately available and had to be requested from the physician's office, with records typically forwarded by secure email the same or next day. This process resulted in the facility not having timely access to essential physician documentation in accordance with accepted professional standards.