Delay in Providing Medical Records to Resident's Representative
Penalty
Summary
The facility failed to provide a resident's legal representative with access to the resident's medical records within the required timeframe, as per federal regulations. The representative of a resident requested copies of the resident's complete medical and physical therapy records via email on May 28, 2024. The facility acknowledged the request and informed the representative that an Authorization for Release of Health Information form was needed. The representative submitted the required form on June 16, 2024, but the facility did not provide the requested records until July 8, 2024, which was beyond the stipulated two working days' notice. Interviews with facility staff revealed that the delay was partly due to the Director of Nursing's responsibility to review all medical record requests before they were processed, which was a directive from the previous Administrator. The Director of Nursing acknowledged awareness of the two-day turnaround requirement but cited other facility priorities as a reason for the delay. The Administrator mentioned the need for clarification regarding the requestor's identity and the specifics of the request, as the representative had not been in contact with the facility during the resident's stay. The Administrator also admitted to not being fully familiar with the medical record request process, which contributed to the delay in fulfilling the request.
Plan Of Correction
Plan of Correction: Approved February 20, 2025 Plan of Correction F573 I. Immediate Action a. Resident #3 is no longer residing in the facility and was discharged to NYP(NAME) Valley on 5/1/24. b. The Director of Nursing received a 1:1 education on 2/19/25 by the Regional Nurse on the Facility Medical Record Policy with emphasis on ensuring all written request for copies of the medical records by the resident/resident legal representative within 2 working days advance notice to the facility is followed. c. The Medical Record Personnel received a 1:1 education on 2/19/25 by the Regional Nurse on the Medical Record Policy with emphasis on ensuring all written request for copies of the medical records by the resident / resident legal representative within 2 working days advance notice to the facility is followed. d. The Facility Administrator received a 1:1 Inservice on 2/19/25 by the Regional Nurse on the Facility Medical Record Policy with emphasis on ensuring all written request for copies of the medical records by the resident resident/legal representative within 2 working days advance notice to the facility is followed. II. Identification of Others a. An audit was conducted on 2/19/25 by the Administrator for all request for medical records by the resident/resident legal representative within the last 14 days with no negative findings. b. The facility acknowledges that all resident who request for medical record has the potential to be affected by this practice. III. System Changes a. The Facility Medical Record Policy dated 9/2024 was reviewed on 2/19/25 by the Medical Director, Administrator, Director of Nursing with no changes made. b. The Administrator, the Assistant Administrator, DNS, ADNS and Medical Record Personnel will be reeducated on the Facility Medical Record Policy. IV. Quality Assurance a. An audit tool was created by the Administrator to audit all medical record request to ensure they are sent out timely. b. Audits will be completed by the Medical Record Personnel weekly x 4, monthly x 2 months and quarterly x 3 quarters. c. All negative findings will be brought to the attention of the Administrator immediately. All negative findings will be immediately addressed by the Administrator /Designee with an onsite teaching/Inservice and disciplinary action as needed. d. All results of the audits will be brought to the QAPI committee quarterly x 4 to review and discuss any unfavorable patterns that may prevent achieving 100% compliance. V. Person Responsible Administrator Completion date: (MONTH) 12, 2025