Failure to Implement Compliance Program for Medical Record Retention
Penalty
Summary
The facility failed to effectively communicate and implement the standards of its compliance and ethics program, specifically regarding the retention and accessibility of resident medical records. During the survey, it was found that medical records dated prior to November 2024 were not accessible due to issues with transitioning between electronic medical record systems. The facility's policy requires retention of all medical records for the period required by law, but this was not followed, as records from the previous system were not available for residents admitted before November 2024. Interviews revealed that the Administrator, who also served as the Corporate Compliance Officer, was aware of the lack of access to these records but did not identify it as a concern or communicate the issue to the Corporate Compliance Committee, the Quality Assurance Performance Improvement Committee, or the Corporate Information Technology Nurse. The Corporate Information Technology Nurse and the Operator both stated they would have expected the Administrator to report the issue for continuity of care. The failure to ensure access to all required medical records was not addressed or escalated as required by the facility's compliance and ethics program.