Failure to Document Social Services Referrals and Follow-Up in EMR
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurate medical records in accordance with professional standards and facility policy for three sampled residents. For one resident, a physician’s order dated 10/9/25 directed a Modified Barium Swallow (MBS) to rule out silent aspiration. Nursing documentation on that date showed the physician made rounds, examined the resident, and issued the new MBS order, and that the Social Services Director (SSD) was notified. An LVN stated it was important for this resident to have the MBS to evaluate swallowing and aspiration risk and that the SSD was responsible for scheduling the test and documenting follow-up in the EMR. However, there was no documentation in the EMR that the SSD scheduled the MBS or followed up on the order. For a second resident, a physician’s order dated 7/22/25 directed a Barium Swallow consult. Nursing notes from the same date documented that the physician examined the resident, issued the new order, and that the Social Services Assistant (SSA) was notified. The LVN reported that this resident had swallowing issues, had a G-tube, and an order for nothing by mouth, and that the SSA or SSD should have scheduled the appointment and documented follow-up in the EMR. The SSD later stated she had contacted the resident’s sister after the hospital indicated a responsible party (RP) needed to attend the appointment to sign consents, and that she called the RP several times. She acknowledged she did not document any of these attempts to schedule the MBS or contact the sister in the EMR. For a third resident, physician’s orders dated 12/10/25 included an EENT consult to assist vocal cord mobility and an MBS to rule out silent aspiration to help determine if a by-mouth diet was possible. An LVN stated this resident had been admitted with a G-tube and had progressed to an oral diet, and that the MBS was ordered to assess safe oral intake. The LVN was unable to locate any documentation that the SSD scheduled the appointment or followed up. The SSD stated this resident had been scheduled for an in-house ENT consultation but was discharged before the appointment and that she did not document the appointment or any follow-up calls in the EMR. The SSD explained that her practice was to keep paper notes and orders in a folder in her office and to enter appointment information in a temporary communication section of the EMR that was automatically cleared and not part of the permanent medical record. Facility policies required that all services provided, changes in condition, and referrals coordinated by social services be documented in the resident’s medical record, and the SSD acknowledged that if something was not documented, it was considered not done.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.