The Lev At San Antonio

During an interview on 8/14/2025 at 1:12 p.m., the DON stated LVN A was not responding to her calls or requests for interview and was unavailable.

The DON stated Resident #1 was sent to the hospital per family request on 7/05/2025.

She stated the resident was only gone for a short amount of time, she thought only a couple of hours and then returned to the facility without any orders.

The DON stated LVN A documented in PCC(Point Click Care) there were no new orders.

She stated this information was obtained by telephone conversation from the hospital to the nurse.

The DON stated as an industry they were experiencing the hospital sending resident back to the nursing facilities without any paperwork or documentation.

She stated the facility process was for the resident's physician to evaluate the resident within a few days of returning from the hospital.

She stated they were not requesting records from the hospital.

The DON stated they are only taking verbal information from the hospital.

The DON stated she believed the facility was providing continuity of care because the physicians were following up within a few days.

She stated she was unsure what the facility policy was for obtaining and retaining hospital records.

She stated typically the medical records person was responsible for uploading any records into the computer.

Record review of a facility policy, titled Maintenance of Medical Records dated 2023 revealed: This facility will maintain clinical records for each resident in accordance with acceptable standards of practice that reflects the current plan of care and services provided as well as in a manageable size for use by the care providers. 2. In accordance with accepted professional standards of practices, the facility must maintain medical records on each resident that are a. complete b. accurately documented c. readily accessible d. systematically organized.

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