Complaint Investigation Report

The investigation revealed the following:

Regarding: Staff are not maintaining complete and accurate records regarding resident in care.

It is alleged that R1 has been asking staff for a copy of resident’s medical records, but staff are only providing records that are incomplete or inaccurate. It is also alleged that medical records are missing due to being misplaced on purpose or because of staff being incompetent.

Staff deny the allegation. Interviews with (5) staff indicated that R1 has received copies of medical records the facility has on file, at R1’s request. S1-S3 indicated that copies of R1’s medical records were provided to R1 on 9/23/25 and R1 signed a Release of Medical Information on 9/23/25 and 10/3/25. S1-S3 indicated that the medical records given to R1 were not incomplete or inaccurate and R1’s documents have not been lost or misplaced. S1-S3 further indicated that the medical records the facility has on file are the medical records R1 volunteered to the facility to have on file and other records obtained from the medical services provided at the facility, before R1 changed their doctors. S1-S5 further indicated that due to R1 managing her medical appointments independently, orders and testing results have not been received by the facility from R1’s doctors. Staff stated that they have advised R1 to follow up with their doctors to obtain their medical information and if needed, facility staff can help. Staff stated that R1 has refused to provide them with their doctors’ contact information and therefore, have not been able to provide R1 with assistance in obtaining the medical records R1 is requesting. Interview with R1 indicated that staff did not give them all their medical records and that staff lose them on purpose. However, interviews with (13) out of (15) residents indicated that they have no concerns with how the facility handles their medical records and that medical records released to them are accurate and complete. Record reviews indicated that S1 provided R1 with the requested medical records on 9/24/25 per the Release of Medical Information forms kept on file, signed by S1 and R1. Record reviews also indicated that the facility does not have orders from R1’s doctors requesting labs or other testing. Tour of the med-tech room revealed that resident medical records are centrally stored, kept locked and inaccessible to unauthorized individuals. Based on interviews, record review and observations, the allegation that staff are not maintaining complete and accurate resident records could not be corroborated.