Failure to Provide Surveyors Independent Access to EHR Documentation
Penalty
Summary
Surveyors were unable to independently access three months of nurse aide documentation for a resident during a survey, despite being provided with the facility's federal Entrance Conference Worksheet and instructions for accessing the Electronic Health Record (EHR). The surveyors required read-only access to the same information available to staff, specifically documentation related to the completion of care tasks such as bathing, toileting assistance, bowel elimination records, incontinence care, behavior monitoring, oral hygiene, and application of medical devices. When the surveyors requested instructions for accessing this documentation, the Nursing Home Administrator responded that she would print the requested records, rather than providing direct access. A licensed practical nurse later printed the documentation for the surveyor, but the surveyor was still unable to independently view the information without staff intervention. This failure to provide surveyors with the same read-only access to residents' EHRs as staff constitutes a deficiency in maintaining and making medical records readily accessible for health oversight activities.