Failure to Document Follow-Up After Cancelled MRI/CT Appointment
Penalty
Summary
The deficiency involves the facility’s failure to maintain a complete and accurate medical record for one resident when ordered diagnostic tests were not completed and follow-up actions were not documented. The resident, who had diagnoses including hemiplegia and hemiparesis following a cerebral infarction, morbid obesity, and lumbar radiculopathy, was chairbound, used a manual wheelchair, and required varying levels of assistance with ADLs according to the MDS. A physician ordered MRI studies of the thoracic and lumbar spine and a CT of the thoracic spine, and these tests were scheduled at an outside testing center. Nursing documentation on the day of the appointment showed that the resident was transported by ambulance for the MRI and CT and later returned without having the procedures completed because of being overweight and not fitting into the scanning machines, with a note that a new place needed to be found. Subsequent review of the medical record by RN 1 revealed no further nursing progress notes describing any follow-up to arrange completion of the MRI and CT after the cancelled appointment. During interview, RN 2 recalled that the resident’s MRI and CT could not be completed due to the resident’s size and stated that a new testing location that could accommodate the resident was needed. RN 2 reported that she endorsed this information to the case manager and to the night shift but acknowledged there was no documentation in the resident’s record reflecting that these endorsements occurred or that any follow-up was initiated by nursing. RN 2 also stated that while the case manager is responsible for finding a new diagnostic testing site, nurses are responsible for follow-up as well. The Director of Admissions, who had been assisting with case management, explained that case managers rely on receiving information about diagnostic test needs and cancellations from nursing in order to obtain insurance approval and schedule appointments, and stated there was no recollection of being informed that the resident’s MRI and CT appointment had been cancelled. The DON confirmed awareness that the MRI and CT had been ordered and that the appointment was cancelled due to the resident’s size, and stated that RN 2 should have documented her endorsement of the cancelled tests so subsequent shifts could follow up. Review of the facility’s “Completion and Correction” policy indicated that medical records are to be complete and accurate, with entries recorded promptly as events occur and documentation reflecting medically relevant information concerning the resident. The lack of documentation of the endorsement and follow-up related to the cancelled MRI and CT resulted in an incomplete and inaccurate medical record for the resident.
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