Failure to Maintain Complete Medical Record for Post‑Surgical Therapy and Orthopedic Care
Penalty
Summary
The deficiency involves the facility’s failure to maintain a complete and accurate medical record for a resident who had complex medical needs, including neurogenic bladder, a stage 4 sacral pressure ulcer, chronic pain, contractures, an indwelling catheter, an ostomy, a feeding tube, and dependence for all care. The resident’s MDS showed intact cognition with a BIMS score of 14, and the care plan identified the need for bilateral elbow extension splints and a custom tilt-in-space wheelchair with gentle range of motion and therapy screening as needed. An APRN progress note documented that the resident was seen by a bone/joint specialist for hand contractures and had a right wrist carpectomy without complications, with left wrist/hand surgery scheduled. A nursing note later documented the resident’s return from a surgical appointment with a left wrist dressing that was clean, dry, and intact and no acute distress. A grievance filed by the resident stated that he/she reported to a hospital bone and joint institute that physical therapy was not being received. The grievance response stated that after the wrist surgery, the required therapy was specialized and could not be completed at the facility, that attempts to arrange outside therapy were complicated by the resident’s special needs, and that therapy had thoroughly evaluated the resident and determined he/she was not appropriate for therapy pending removal of a wrist splint by the orthopedist. However, record review did not identify any therapy notes or records related to the wrist surgery, any documentation of the orthopedic procedure on the left wrist, or any outside consultations prior to a specified date. The facility was unable to provide any therapy documentation for 2021 or outside consultations before that date. In interviews, the APRN and DON both stated that documentation of the orthopedic procedure, therapy evaluations, any therapy provided, or reasons therapy was not provided, and orthopedic consultations/surgeries should have been included in the resident’s medical record, consistent with the facility’s Charting Documentation Policy requiring all services and changes in condition to be documented.
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