Failure to Maintain Complete and Accessible Medical Records
Penalty
Summary
The facility failed to maintain complete, accurate, and accessible medical records for a resident who had been discharged. The resident did not receive their Social Security benefits and, upon contacting the Social Security Administration (SSA), was informed that the cessation of payments was due to being incorrectly identified as still residing in the facility. The resident reached out to the facility's Business Office Manager, Administrator, and Social Services Director for assistance but did not receive a response. A DSHS case manager also contacted the Social Services Director to facilitate the completion of a required SSA form, but the form was left incomplete because the Social Services Director no longer had access to the resident's records after discharge. A review of the electronic health record (EHR) system showed no available record for the resident at the time of the request. The Medical Records staff indicated that records could only be obtained by requesting them from the previous facility ownership. The requested medical records were not received until two and a half days later. The incomplete documentation and lack of timely access to the resident's records resulted in the inability to complete necessary forms for the resident's Social Security benefits.