Missing Consultant Reports in Resident Medical Record
Penalty
Summary
The facility failed to maintain complete and accurate medical records when consultation reports for one resident were missing from the resident’s chart. The resident, who had diagnoses including anxiety disorder, major depressive disorder, and bipolar disorder, was originally admitted in 2022 and readmitted in early 2023. An MDS assessment indicated the resident had intact cognition and was able to understand and be understood by others. The resident reported that she had several consultation appointments in 2025 and that her physician informed her that the consultation notes were not present in her medical record. During a concurrent interview and record review with the Medical Records Director, it was confirmed that not all of the resident’s 2025 consultation reports were in the medical record and that they should have been placed in the chart or uploaded. The missing documents included orthopedic and neurology consultation notes, which the Medical Records Director stated should be available so physicians and staff could refer to them and have a clearer picture of the resident’s health. The DON also stated that consultant notes should be in the resident’s medical record. The facility’s undated policy titled “Accuracy of Medical Records” indicated that all medical records are to be complete, accurate, and updated to reflect care and services provided to each resident.
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