F0842

D

Missing Physician/NP Documentation in Electronic Medical Records

Brownsville, Texas Survey Completed on 03-25-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to maintain complete and accurate clinical records in accordance with accepted professional standards for two residents. For the first resident, an older male with multiple complex diagnoses including cerebral infarction with right-sided involvement, Parkinson’s disease, Alzheimer’s disease, end-stage renal disease on dialysis, and Type 2 diabetes mellitus, the electronic medical record lacked any physician or nurse practitioner documentation over an extended period. The resident’s MDS showed he was nonverbal, rarely/never understood or able to understand others, and was fully dependent for toileting, showering, and personal hygiene, with continuous bladder and bowel incontinence. Nursing progress notes documented that a family nurse practitioner (FNP) assessed the resident on several dates in January, February, and March and made medication changes and follow-up plans, but there were no corresponding physician or NP notes entered in the Progress Notes or Miscellaneous sections of the electronic record from 01/21/2026 through 03/24/2026.

For the second resident, an older female with diagnoses including hypertension, Type 2 diabetes mellitus, heart disease, and other toxic encephalopathy, the facility similarly failed to maintain physician or NP documentation in the electronic record. Her MDS reflected a BIMS score of 9, indicating moderate cognitive impairment, with clear speech and usual ability to understand and be understood, and a need for substantial/maximal assistance with toileting and showering, along with frequent bladder and occasional bowel incontinence. A nursing progress note documented that an NP was in the facility, was notified of the resident’s high blood sugar and the family’s request to review and discontinue some medications, and that the NP acted on this request. However, there were no physician or NP notes in the Progress Notes or Miscellaneous sections for this resident from 02/21/2026 through 03/24/2026.

Interviews with facility leadership confirmed that the absence of provider documentation in the electronic medical record was inconsistent with facility expectations and policy. The DON stated that physicians and NPs should have notes in the Progress Notes or Miscellaneous sections of the electronic chart, and that they typically wrote notes on paper which were then uploaded into the Miscellaneous tab. She acknowledged not knowing why the two residents’ charts lacked doctor or NP notes and stated that if such notes were not in the computer, the resident’s progress or status would not be shown. The Administrator similarly stated that there should be physician and NP notes in the electronic system and that providers were usually on their computers while in the facility, but she did not know how or why there were no notes for these two residents. The facility’s “Documentation in Medical Record” policy required that each resident’s record contain an accurate representation of the resident’s experiences, with complete, accurate, and timely documentation of assessments, observations, and services, completed at the time of service or by the end of the shift, and containing sufficient detail about the resident’s care and responses to care.