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Based on the review of records, interview and policies and procedures review, the facility failed to honor 1 (Patient #1) of 5 patients' rights by not maintaining a current, accurate, and complete medical record as required.

Findings include:

Review of Patient #1's clinical record conducted on 07/24/2024 revealed:

Hospital Course: After cesarean section delivery of a baby girl on 09/01/2022, Patient #1 was transferred to the intensive care unit for continued close observation due to severe thrombocytopenia. On 09/06/2022, Patient #1 underwent a bone marrow biopsy performed by the hematologist. After midnight, Patient #1 was in critical condition and expired (possible Immune thrombocytopenia - a blood disorder that causes low platelets and bleeding).

Interview conducted on 07/24/2024 at 3:30 PM with the Chief Nursing Officer (CNO) revealed the facility changed electronic medical record systems on October 25, 2022, and they are unable to provide the following documents for Patient #1:

1. Nursing Assessments
2. Medication Administration Records
3. Respiratory Assessments/Notes
4. Stroke Team Assessments/Notes

The CNO stated that the facility ceased providing obstetric and neonatal intensive care services as of February 14, 2024, and the Medical/Nursing staff are no longer employed at the facility.

Review of the facility's policy entitled Record of Care Policy Number: ROC 52; Last Revised 09/29/2022 included but wasn't limited to:

Policy: The facility supports the right of an individual to access their accurate and complete health information in a timely manner. In all cases the facility promotes the guarantee of an individual's right to access their health information under applicable law and the facility policies and procedures.

Review of the facility's policy entitled Policy Document Retention Policy Department: Compliance Policy Number: COM 32; Last Revised 09/26/2023 included but wasn't limited to:

Policy: The facility retains business and clinical documents for a period of time no less than required by law. Each department Director or Practice Operations/ Administrative Director is responsible for the proper retention, storage and disposal of documents that it generates, maintains and/or receives in the course of doing business.

A review of the form entitled Document Retention Schedule, last reviewed on 09/26/2023 documented medical records in Florida hospitals should be retained for adults seven (7) years after the last entry.

The facility failed to provide a true and accurate medical record containing information from patient observations, interviews, and treatment provided by medical staff.