Failure to Safeguard and Retain Resident Medical Records
Penalty
Summary
The facility failed to maintain a complete and safeguarded medical record for one resident following admission from an acute care hospital. The resident, who had diagnoses including hip fracture post-surgery, hypothyroidism, hypertension, and arthritis, was admitted without proper documentation of signed admission physician's orders. There was also no evidence that the discharge summary and medication list from the hospital were reviewed or communicated to the attending physician, and no progress note was written to document physician contact or new orders. The facility's policy required reconciliation of medications and documentation of physician orders, but these steps were not followed for this resident. Additionally, the original hospital discharge orders for the resident were shredded by the Medical Records Coordinator, who stated she was instructed by an interim DON to destroy paper records as the facility transitioned away from paper charts. This shredding occurred for several months and included records from multiple residents, with no record kept of what was destroyed, contrary to facility policy and regulatory requirements. The Administrator and current DON were unaware of this practice until it was discovered during the survey, and the facility's policy for proper destruction and retention of medical records was not followed.