Incomplete and Inaccessible Medical Records Following Ownership Change
Penalty
Summary
The facility failed to ensure that complete and readily accessible medical records were maintained for a resident who was admitted with diagnoses including anemia in chronic kidney disease, chronic obstructive pulmonary disease, and type 2 diabetes. Upon review, it was found that the clinical record contained no documentation of any entries prior to a change in facility ownership. The facility's Administrator confirmed that they were unable to obtain certain parts of the electronic records from the previous owners, as access was denied despite attempts to retrieve the information. The Therapy Director also reported being unable to access records prior to a specific date. This deficiency was identified during a review of clinical records, interviews with facility staff, and examination of facility documentation. The lack of accessible records was further highlighted by a complaint filed with the State Agency, which indicated that the resident did not receive the insurance-authorized time for therapy during her admission. Arizona state law requires health care providers to retain medical records for at least six years, but the facility was unable to produce records for the period before the change in ownership.