Medical Audit Trail at Issue in Nursing Home Wrongful Death Case

5 Sep 2016

In Clouser v. Golden Gate National Senior Care, LLC, et. al., Case No. 15-33 (W.D. Pa., Aug. 9, 2016), Plaintiff sued Defendants for the wrongful death of decedent, an Alzheimer’s patient living in one of Defendants’ nursing facilities. The facility kept poor, false or incomplete records of the decedent’s condition, and ultimately, he died of sepsis from untreated wounds. After certain counts were dismissed and others sent to arbitration, discovery began as to the wrongful death claim. Plaintiff served interrogatories and requests for production upon Defendants, to which Defendants responded; Plaintiff requested a supplemental response. Defendants did not provide one. Plaintiff filed a motion to compel.

With respect to the requests for production, Plaintiff sought, among other things, a full and complete copy of the audit trail for the decedent’s medical records, including information about when his chart was accessed and by whom. Part of Plaintiff’s claim rested upon her allegation that his chart was falsely documented, and she asserted that the audit trails were relevant. Defendants responded that they are not required to maintain an audit trail and that they do not maintain them because their medical records are not “single documents” but “an amalgamation of multiple computer programs and systems provided by different vendors.” Defendants offered to produce various reports that they asserted would provide Plaintiff with the same information.

The court determined that although Plaintiff specifically requested an audit trail, the information Defendants offered in its stead would provide Plaintiff with what she sought, and it denied the Motion to Compel the audit trail as moot.

ILS – Plaintiff eDiscovery Experts