Failure to Develop Protocol for Medical Record Requests
Summary
The facility failed to develop a protocol for the release of medical records requested on behalf of a resident's legal representative, resulting in a deficiency. The medical record request log from January 2024 to September 2024 showed no entries related to the resident in question. An interview with the Medical Records staff revealed that two requests for the resident's records were received, but these were forwarded to the former owners without a tracking mechanism to verify completion. The Director of Nursing acknowledged the lack of a process to handle such requests when they cannot be honored by the current facility. Further interviews with the Nursing Home Administrator (NHA) revealed that legal requests for medical records are sent to a third-party vendor for validation. The first request was denied, and the outcome of the second request was unclear due to it being sent to the wrong person. The NHA noted that the staff responsible for handling these requests was new to the position and that there was no written policy or protocol to ensure that legal requests submitted on behalf of a resident's representative are honored.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A resident with type 2 DM, anxiety, adult failure to thrive, and vascular dementia had a BIMS score of 04 and was not interviewable. Her representative requested access to her medical records, but staff denied the request because they questioned the validity of the MPOA/POA on file, and the DON and Administrator acknowledged delays in providing the records while the document was being reviewed.
Failure to Provide Requested Medical Records: A resident with DM and Parkinson’s disease, who could make needs known but could not make medical decisions, had a valid request for medical records submitted by the law firm representing the resident’s legal representative. The facility did not provide the records within the required timeframe, and the MRD confirmed the request had been received but the records had not been sent by the time of survey.
Failure to Provide Requested Medical Records: A resident with epilepsy, DM2, COPD, and severely impaired cognition had an authorized RP request copies of medical records by eFax, but the facility did not send the records until well after the requested release timeframe. The MRD acknowledged the delay, and the ADM stated the records should have been available within two working days after request.
Failure to Release Resident Records to Authorized Representative: A resident with severe cognitive impairment and a family member identified in the admission paperwork as her representative had records requested after discharge, including incident-related documents and the full medical record. The family member said he requested the records by letter and phone, but the DON, ADM, and medical records staff required a POA before release and did not provide the records as requested, despite facility policy stating a resident may authorize release of personal and clinical records and that a release form is needed when family requests records.
Failure to Timely Release Resident Medical Records: The facility did not process and release a resident's medical records in accordance with policy and federal requirements. A resident with COPD, acute respiratory failure, and type 2 DM had records requested by an authorized representative, but the law office reported repeated unanswered attempts and no records received for months. Facility documentation showed delayed contact with the requester, despite the privacy policy requiring prompt access to records upon request.
Delay in Release of Medical Records: The facility failed to provide a resident's medical records to the resident's representative and legal representative within the required timeframe. A resident admitted with DVT had a signed ROI on file, but the records were not released promptly after requests from the family and a lawyer's office. The DON/administrator acknowledged records should be released within 24 to 48 hours, but documentation did not show when the records were picked up or when the first legal request was made.
Failure to Provide Requested Medical Records
Penalty
Summary
The facility failed to provide Resident #30 and her representative access to her personal and medical records within 24 hours of request. Resident #30 was admitted and re-admitted to the facility, had diagnoses including type 2 diabetes, anxiety disorder, adult failure to thrive, and vascular dementia, and had a quarterly MDS assessment showing a BIMS score of 04, indicating severe cognitive impairment. She was documented as not interviewable during observation, and her medical power of attorney dated 01/03/2020 identified her representative as the person authorized to make health care decisions on her behalf. During interview, the representative stated she had contacted Medical Records, Social Worker, DON, and the Administrator about obtaining Resident #30's records and was told she was not the legal representative and that the MPOA/POA on file was not valid, so she would not have access to the records. The Ombudsman reported the facility was questioning the signed POA and denied the request based on concerns about validity. The DON and Administrator both acknowledged delays in providing the records because the MPOA was being reviewed for validity, and the DON stated the legal team had been reviewing the document.
Failure to Provide Requested Medical Records
Penalty
Summary
The facility failed to provide Resident 6’s medical records within the required timeframe after receiving a valid request from the law firm representing the resident’s legal representative. Resident 6 was admitted with diagnoses including type 2 diabetes mellitus and Parkinson’s disease, and the history and physical indicated the resident could make needs known but could not make medical decisions. A request for medical records was faxed to the facility on 5/15/2026, along with an authorization for release of medical information signed by the resident’s legal representative. During interview and record review, the Medical Record Director stated the request was received on 5/15/2026 and that the records were not sent by the time of the survey on 5/28/2026. The Administrator and Medical Record Director referenced the facility’s policy, which stated requested copies of the record should be sent within 48 hours of receipt of a valid written request, while the Administrator stated the facility had 15 days to send medical records to law firms.
Failure to Provide Requested Medical Records
Penalty
Summary
The facility failed to provide requested medical records to the responsible party of one sampled resident. Resident 1 was admitted on 11/29/2016 with diagnoses including epilepsy, type 2 diabetes mellitus, and COPD. The resident’s 9/4/2024 MDS indicated severely impaired cognitive skills for daily decision making. On 2/25/2026, an Authorization for the Release of Medical Information named RP 2 as the recipient authorized to receive Resident 1’s health information, business office files, billing records, and writings pertaining to medical history and treatment. The facility received RP 2’s request for Resident 1’s medical records by eFax on 4/23/2026. The Medical Records Director stated she received the request that day and emailed RP 2 on 5/6/2026 stating the records would be available at the end of that week. The requested records were not sent until 5/11/2026, which was 16 days after the date the records were supposed to be released. The facility’s policy stated discharged residents or their authorized representatives may request and receive a copy of the medical record within 15 days, and the Administrator stated the State Operation Manual indicated the facility must allow the resident to obtain a copy of the records or any portions thereof upon request and two working days advance notice to the facility.
Failure to Release Resident Records to Authorized Representative
Penalty
Summary
The facility failed to treat the decisions of a resident representative as the decisions of the resident to the extent delegated by the resident for one resident whose records were reviewed. The resident had been admitted with diagnoses including orthostatic hypotension, a personal history of malignant neoplasm of the breast, and acquired absence of the right breast and nipple. Her MDS assessment showed a BIMS score of 5 out of 15, reflecting severe cognitive impairment, and participation in assessment and goal setting included the resident and a family member. Her admission paperwork identified a family member as the representative and emergency contact, and the resident preferred that family member to sign the disclosure authorization. After the resident was discharged, the family member requested copies of records related to an incident, including incident reports, nursing and clinical notes, staff names and titles, facility policies, internal documentation, and CT scan results. The family member stated he also requested the resident’s medical records by letter and by telephone. The facility responded that it could provide copies of the resident’s medical records only after receiving a completed medical records authorization from the legally authorized representative, and staff told the family member that a POA would be needed before records could be released. The DON stated the family member had requested the resident’s entire medical record but would not provide a POA, and corporate advised that the records could only be released if a POA was provided. The medical records staff stated she could release records with an authorization for release of medical records and that legal would verify POA status, but she also followed facility protocol. The administrator stated he had been advised by the legal team that records could only be released to the family member upon provision of a POA, and the facility policy stated that a resident may authorize release of personal and clinical records as provided by law and that if records are requested by family, a medical records release form must be completed.
Failure to Timely Release Resident Medical Records
Penalty
Summary
The facility failed to ensure medical records were processed and released in accordance with facility policy and federal regulations for one resident. The resident was admitted on April 2, 2025, and had diagnoses including chronic obstructive pulmonary disease, acute respiratory failure, and type 2 diabetes mellitus. The issue involved the resident's authorized representative, who had requested copies of the resident's medical records from the facility beginning on January 28, 2026. A law office staff member stated during telephone interview that the office had made multiple requests for the records and had still not received them. A fax cover sheet from the law office documented repeated attempts to obtain the records and noted that calls were being routed to voicemail without response. Facility documentation showed the facility did not contact the law office until May 7, 2026, after the request had been pending for more than three months. The DON reviewed the facility's privacy policy, which stated records would be provided upon request within 24 hours excluding weekends and holidays, and the State Operations Manual guidance stating the facility must allow the resident to obtain a copy of the records upon request and 2 working days advance notice.
Delay in Release of Medical Records
Penalty
Summary
The facility failed to ensure medical records were provided to a resident's representative and legal representative within 48 hours of request for 1 of 3 sampled residents reviewed for release of medical records. Resident #1 was admitted with a diagnosis of deep vein thrombosis and later discharged from the facility. The facility's Release of Information policy stated that a resident may obtain photocopies of records by providing at least 48 hours' advance notice, and that information in the medical record may only be released by written consent of the resident or legal representative. A release of confidential information form signed by the resident's representative was dated 12/19/25, and a copy of the resident's medical records showed they were printed on 12/29/25. Family member #1 reported that the resident's representative requested records on 12/19/25 and did not receive them until 01/02/26. A lawyer's office also requested the resident's records on 01/12/26, 02/02/26, and 03/31/26, and the facility sent the records on 03/31/26. The administrator stated medical records should be released 24 to 48 hours after the release of information is signed, but there was no documentation of when the records were picked up by the resident's representative or when the lawyer's office first requested the records.
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