Incomplete and Disorganized Medical Records for Multiple Residents
Penalty
Summary
The facility failed to maintain complete, accurate, readily accessible, and systematically organized medical records for four out of nine residents reviewed. For one resident with dementia, malnutrition, and diabetes who was receiving hospice care, hospice visit notes were missing for several weeks despite ongoing weekly visits, and there were no facility provider progress or visit notes in the medical record. Another resident with diverticulitis, heart failure, and muscle weakness had no facility provider physician progress or visit notes, and their emergency contact information was missing from the demographic section of the medical record, even though it was available on the admission referral. A third resident with encephalitis, severe intellectual disabilities, and dysphagia had no recent facility provider progress or visit notes, with the last note dated over a year prior. A fourth resident with respiratory failure, heart failure, and diabetes also had no documentation of a facility provider visit or progress note. Staff interviews revealed that the process for scanning and organizing medical records was significantly delayed, with a backlog of about six months, and that staff had difficulty accessing provider notes, which were stored in a separate system only accessible by the Medical Records Director. Staff acknowledged that the facility was not following its own policies for health information management, which required that records be complete and accessible. The lack of timely scanning and integration of documents, as well as incomplete demographic information, contributed to the deficiencies in maintaining accurate and accessible medical records for residents.