Failure to Maintain and Integrate Therapy Documentation in Medical Records
Penalty
Summary
The deficiency involves the facility’s failure to follow its policies and procedures for progress notes, charting, and documentation of therapy services for five sampled residents. For each of these residents, physician orders were in place for PT, OT, and/or ST at specified frequencies and durations, but there was no corresponding documentation of the therapy treatments or services in the facility’s electronic medical record. The residents had diagnoses such as muscle weakness, abnormalities of gait and mobility, and dysphagia, and were admitted and, in some cases, discharged during the time periods when therapy orders were active. Record review showed that one resident admitted with muscle weakness had orders for PT five times per week for 12 weeks and OT twice per week for 12 weeks, but there was no documented evidence of PT or OT services provided. Another resident with muscle weakness and gait abnormalities had orders for PT, OT, and ST, yet the electronic medical record contained no documentation of any of these therapies. A third resident with gait and mobility abnormalities had orders for PT and OT, but again, no therapy treatment notes were found in the electronic record. Two current residents with gait and mobility abnormalities, and in one case dysphagia, had active orders for PT and/or ST, but there was no documentation of therapy services in their electronic medical records. Interviews with facility staff confirmed the absence of therapy documentation in the electronic medical record. The MDS coordinator verified that there were no PT, OT, or ST treatment notes available in the system and stated that therapy staff should document after each session. The medical records director confirmed there were no therapy treatment notes or care plans accessible and reported having no access to any therapy documentation, despite stating that such documentation should be part of the resident’s medical record. An LVN reported being unable to access therapy documentation and noted that access would help understand residents’ functional progress. The DON confirmed that no therapy treatment documentation was available in the electronic record and that staff should have access to review it. The director of rehabilitation acknowledged that therapy documentation was not included in the facility’s electronic system, explaining that it took a long time to load and was only provided upon request, while also stating that these documents are part of the resident’s medical record. Facility policies on Progress Notes and Charting and Documentation required that progress notes be maintained for residents receiving specialized rehabilitation services and that treatments or services performed be documented in the medical record, which was not done in these cases.
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