Incomplete Access to Resident Medical Records and Logs During Survey
Penalty
Summary
The facility failed to provide accurate and complete access to all resident medical records during an annual recertification survey. Upon entry, surveyors requested access to the electronic health record (EHR) system and the Grievance log. Although initial access to the EHR was provided, it was incomplete and did not include essential documents such as Medication Administration Records (MAR), Treatment Administration Records (TAR), various assessments, care plans, nutritional reports, and laboratory results. Despite repeated notifications to the Administrator and Director of Nursing Services (DNS) about the incomplete access, the issue persisted over several days. The DNS indicated that the corporate office was hesitant to grant full access to all medical records. Additionally, the Grievance log provided was outdated and, even after requests for an updated version, did not include all reported grievances. The lack of timely and complete access to these records had the potential to delay the survey process and hinder the ability to address resident concerns. The events documented show a pattern of delayed and incomplete responses to surveyor requests for required documentation, as well as uncertainty among facility leadership regarding how to resolve the access issues.