Incomplete Medical Record and Lack of Follow-Up Documentation
Penalty
Summary
The facility failed to maintain a complete and accurate medical record for one resident, resulting in missing documentation regarding a recommended MRI and inadequate follow-up after a significant change in the resident's condition. The resident, who had multiple complex diagnoses including cervical disc disorder, spinal stenosis, diabetes, quadriplegia, and a suspicious right adnexal mass, was admitted with a need for extensive assistance with activities of daily living. An ultrasound identified a large mass and recommended an MRI, which was scheduled three times, but there was no documentation in the medical record confirming whether the MRI was completed or the results obtained. Additionally, after the resident experienced elevated blood pressure and received new medication orders, there was no documented follow-up or further communication with the physician until vital signs were recorded again several weeks later. Interviews with the DON and an LPN revealed a lack of awareness regarding the facility's documentation policy and an inability to confirm whether the MRI was performed or why appointments were rescheduled. The facility's policy requires that the medical record facilitate communication among the interdisciplinary team regarding the resident's condition and response to care, but this was not achieved in this case. The deficiency was identified during the annual survey and was also investigated under multiple complaint numbers.