Failure to Provide Timely Access to Resident Medical Records
Penalty
Summary
The facility failed to provide timely access to a resident's medical records as required, specifically for one resident whose records were requested by an attorney. The process for handling medical record requests was disrupted when the staff member responsible for medical records was terminated, and the responsibility was transferred to the Business Office Manager, who was coordinating with the Regional Medical Records person. There was confusion and lack of communication regarding the receipt and processing of the request, with the Administrator and other staff members unaware of the outstanding request until much later. Documentation shows that the attorney's office made multiple attempts to request the records, including sending faxes, making phone calls, and mailing the request. The facility's fax numbers and process for handling requests contributed to the delay, as one fax number went directly to a copier/fax machine and was not monitored as closely as the secure fax/email. The previous medical records staff member indicated that she had started processing the request but was terminated before completion, and the request was not properly handed off or tracked. The facility's own policies require that all medical record requests be given to the Administrator and outline steps for processing such requests, including verification of authority and notification of costs. However, these procedures were not followed, resulting in a significant delay in providing the requested records. The deficiency was identified through interviews, record reviews, and documentation of the multiple attempts made by the attorney's office to obtain the records.