Failure to Maintain Accurate and Resident-Specific Medical Records
Penalty
Summary
The facility failed to maintain accurate and resident-specific medical records in accordance with accepted professional standards for two residents. Specifically, one resident's hospital records were incorrectly uploaded and attached to another resident's medical chart, while the correct resident's chart did not contain her own hospitalization records. This error was identified during a review of the medical charts, where it was found that the hospital records for one resident were present in the chart of another, and missing from the appropriate chart. Interviews with facility staff, including the DON, MDS Nurse, and RSC, confirmed that multiple staff members have the ability to upload documents to resident charts. Staff acknowledged that uploading documents to the wrong chart is a privacy issue and that there are procedures in place to notify administration and correct such errors. The facility's policy requires that medical records be maintained in a manner that protects electronic protected health information from unauthorized use or access, but this standard was not met in this instance.