Failure to Provide Timely Access to Medical Records
Penalty
Summary
The facility failed to provide a copy of a discharged resident's clinical record within two working days as requested by the legal representative of Resident 18. The resident was admitted to the facility on November 19, 2024, and discharged on December 27, 2024. A formal written request for an electronic copy of the resident's complete medical record in Adobe Acrobat (.pdf) format on a CD was submitted by the resident's representative on January 14, 2025. However, as of the survey ending April 23, 2025, the requested records had not been provided. The facility's policy required written consent for the release of information and assigned responsibility for medical record services to the medical records practitioner. Despite this, the Medical Records Director confirmed that the signed authorization was received in February 2025 but was not acted upon. The Director was unaware of the federal requirement to provide records within two working days and admitted that the facility did not provide electronic records despite having the capability to do so. The resident's representative was verbally informed of a paper-based fee structure but was not provided a written fee schedule. Interviews with the Medical Records Director and the Director of Nursing revealed a lack of awareness and capability in fulfilling electronic record requests, despite the facility's use of an electronic health record system. The Nursing Home Administrator confirmed the facility's failure to provide the requested records. The facility was unable to provide documentation of a written fee schedule or evidence of efforts to fulfill the electronic record request.