Failure to Maintain Access to Resident Medical Records During EMR Transition
Penalty
Summary
The facility failed to maintain access and availability to resident medical records for all sampled residents whose records were created prior to a specific date. This deficiency was identified through policy review, review of an EMR Provider Transition Checklist, administrator emails, medical record review, and interviews. The facility's policy required retention of medical records in accordance with federal and state laws, and guaranteed residents or their legal representatives the right to access their records upon request. However, due to a transition in EMR providers and a change in facility ownership, the facility lost access to the previous EMR system and was unable to retrieve or provide medical records for any of the ten sampled residents for the period before the transition date. The transition process involved the discontinuation of the previous EMR system, with staff instructed to switch to paper documentation for a period until the new EMR system was implemented. Documentation from the transition period indicated that the previous EMR provider would not grant continued access after the change in ownership, and the clinical module of the new EMR would not be available until several weeks later. The administrator confirmed in interviews that the facility had no access to the prior records and had not been successful in retrieving them from the previous owner or EMR provider. The affected residents had a range of medical conditions, including chronic obstructive pulmonary disease, heart failure, schizophrenia, hemiplegia, Parkinson's disease, Alzheimer's disease, diabetes, and others. Some residents were cognitively intact, while others were severely cognitively impaired. For each of these residents, the facility was unable to provide any medical records from before the transition date, as required by policy and regulation.