Failure to Maintain Accessible and Secure Medical Records
Summary
The facility failed to ensure that medical records for a resident were filed in an accessible manner, as required by regulation. During a review of the resident's electronic and paper medical records, key documents such as the "Inventory of Personal Possessions" and the admission "History and Physical" were missing and could not be located when requested. The Director of Nursing (DON) indicated these documents should have been in the paper chart in the medical records department, but they were not present. Later, the "History and Physical" was found in the Admissions office, and the location of the "Inventory of Personal Possessions" was not explained. Additionally, the facility was unable to provide a policy and procedure regarding the completeness, accuracy, and presence of medical records when requested. The facility also failed to ensure that medical records did not leave the premises without proper authorization. It was observed and confirmed that a physician had taken a resident's medical records home, which is not permitted unless expressly authorized by the Department. This action resulted in a delay in locating the resident's "History and Physical" and had the potential for the medical records to become lost. The lack of accessible and properly stored medical records caused delays in medical record accessibility for the resident, who had a history of left hip replacement and required supplemental oxygen.
Penalty
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