Incomplete and Misfiled Closed Medical Record for a Discharged Resident
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurate clinical records for a resident in accordance with accepted professional standards. During a complaint survey, a nurse surveyor requested all closed paper documents and electronic medical record access for Resident #1, who had been admitted after a hospital stay for cardiac symptoms and later discharged from the facility. The Director of Medical Records provided a folder identified as the closed medical record for Resident #1. Upon review, the surveyor found that several documents in this folder actually belonged to another resident (Resident #3), indicating that the resident’s closed record was not accurately compiled. In an interview, the Director of Medical Records stated that the contents of Resident #1’s closed record folder were what had been received from the nursing unit and also acknowledged that Resident #1’s record had not been officially deemed closed because the documents were not in a red folder. The report notes that documentation is an integral part of medication administration and that inaccurate medication documentation can place residents at significant risk of medication error and provide incomplete or inaccurate information for providers and caregivers. The findings show that the facility did not have a system in place to ensure that clinical records, including medication documentation, were complete and accurately maintained for this resident.
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