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F0838
E

Failure to Implement EHR Downtime Contingency Plan and Staff Training

Davis, California Survey Completed on 04-18-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to implement its facility assessment and ensure staff adherence to the established contingency plan during an electronic health record (EHR) system downtime. When the EHR became inaccessible due to an internet outage, nursing staff were not provided with timely direction and were unaware of the procedures to follow. The Director of Nursing (DON) stated that nurses were expected to print medication administration records (MARs) from a backup computer, but the backup computer was also not functioning, requiring staff to use a different computer. Multiple licensed nurses reported that upon arrival, they were informed of the system outage by the night nurse, but had not received any guidance from management and were not aware of the contingency plan for EHR outages. There was no prior notification from management regarding the outage, and staff were left waiting for instructions. Interviews with the DON and Administrator (ADM) confirmed that no mock drills had been conducted for an EHR outage, despite facility policies indicating that such drills should be performed. Review of the facility's assessment and policies showed that procedures and drills for EHR outages were outlined, but these were not followed or communicated to staff during the incident. As a result, there were delays in medication administration, with the potential to affect the health and safety of the facility's 104 residents.

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