Incomplete and Inaccessible Medical Record for Discharged Resident
Penalty
Summary
The facility failed to maintain a complete and readily accessible medical record for one of eight sampled residents. Specifically, the medical record for a resident who had been discharged was incomplete and not available upon request, as required by the facility's policies and procedures. The missing documentation included physician's orders, assessments, progress notes, and discharge planning information. This lack of documentation meant the facility could not demonstrate that appropriate discharge planning and teaching had been provided to the resident and their family member. Interviews with the Medical Records Director revealed that discharged residents' medical records were sent to an offsite storage company and were supposed to be retained for ten years. However, when the record was requested, it could not be located among the boxes received from storage, and the log used to track the location of stored records was incomplete and missing key information. As a result, the facility was unable to provide the required documentation for the resident's discharge, in violation of its own policies.