F0842

D

Failure to Maintain Complete Physician Progress Notes in Medical Record

Schertz, Texas Survey Completed on 01-28-2026

Penalty

No penalty information released

Summary

The facility failed to maintain complete and accurately documented clinical records when physician progress notes for one resident were not obtained and uploaded into the electronic medical record. The resident was an older female admitted with acute kidney failure, essential hypertension, and rheumatoid arthritis, and a quarterly MDS showed she was cognitively intact with total functional dependence for movement. Record review on 1/28/2026 showed no physician notes in her electronic medical record. The DON confirmed that no physician progress notes had been uploaded and later produced paper physician notes dated 3/21/2025, 10/15/2025, and 11/17/2025, none of which were in the electronic record because the facility was behind with uploads.

The Medical Records staff reported he was not on an email group with the facility physicians, had noticed physicians were behind in providing notes, and only requested and uploaded specific documents when someone asked for them, stating that physician notes were not coming to him unless specifically requested. He stated his role was to upload and scan documents and that he had no defined timeframe for doing so. The DON stated physician offices were behind in sending notes, that the Administrator was responsible for contacting physician offices, and that she was not providing medical record oversight, which was handled by an unspecified corporate person. The Administrator acknowledged awareness that some physician offices were behind in sending documentation, had no system for routinely requesting physician notes, and only requested what was needed at the time, despite a facility policy stating it was the facility’s responsibility to notify physicians when progress notes were due and that routine chart audits should identify which physicians needed to be notified.