F0842

E

Failure to Maintain Complete and Accurate Medical Records and Care Plan Documentation

Easton, Maryland Survey Completed on 03-12-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to maintain complete and accurate medical records in accordance with accepted professional standards for multiple residents. For one resident, a complaint alleged that toenails were so long they were growing into the skin. Review of the paper and electronic medical records did not show any podiatry documentation, despite staff stating the resident had been seen by a podiatrist due to thick toenails. The DON was initially unable to locate podiatry notes in the EMR and later produced podiatry visit notes for this resident and 27 other residents, confirming that these office visit records had never been uploaded into the residents’ medical records.

The deficiency also includes missing documentation of care plan meetings for three other residents. One resident’s record showed the last documented care plan meeting several months earlier, with only an invitation for a more recent meeting and no record that the meeting occurred until the social worker later produced a paper care plan summary that had not been uploaded. Another resident had a scheduled care plan meeting with no evidence of the meeting in the medical record until the social worker provided paper notes kept in an office file. A third resident’s record showed the last care plan meeting many months prior, and the resident was unsure of the last meeting date; the social worker then produced paper notes of a more recent care plan meeting that were also not in the medical record. The social worker reported keeping care plan documentation on paper in a file cabinet and stated that due to workload, these notes were not consistently uploaded into the EMR and expressed uncertainty about the requirement for them to be in the medical record.