Failure to Maintain Complete Medical Records and Document Wound Care
Penalty
Summary
The facility failed to maintain complete and accurate medical records for two residents, as required by accepted professional standards. For both residents, there was no documentation of an initial physician visit note in their medical records, even after more than 90 days following admission. Review of the electronic medical record (EMR) and progress notes for both individuals did not reveal any physician or MD notes, except for a single nurse practitioner (NP) note for one resident. Interviews with facility staff, including the Director of Nursing Services (DNS) and the administrator, confirmed that physician documentation was missing and that it was the responsibility of the medical records department to ensure such documentation was present. The physician later admitted to forgetting to send the required history and physical documentation for both residents to the facility. Additionally, the facility failed to document wound care provided to one of the residents on three separate occasions, as required by the resident's treatment orders. The Treatment Administration Record (TAR) for the month in question showed blank entries for the scheduled wound care on three specific dates. Interviews with nursing staff indicated that the absence of documentation could mean the treatment was completed but not recorded, or that the nurse responsible was not present and coverage was provided by other staff. However, there was no documentation to confirm that the wound care was actually performed on those dates, nor any explanation for the missed entries. Both residents involved had significant medical histories, including diagnoses such as Alzheimer's disease, chronic kidney disease, dementia, and chronic obstructive pulmonary disease. One resident was on hospice care and had a documented stage 3 pressure wound requiring daily treatment. The lack of physician documentation and incomplete wound care records were confirmed through record review, staff interviews, and review of facility policies, which required accurate and timely documentation of care and physician services.