Failure to Timely Address Medical Record Request
Penalty
Summary
The facility failed to address a request for medical records in a timely manner for a resident with severe cognitive impairment and multiple diagnoses, including altered mental status, psychosis, encephalopathy, anxiety, restlessness and agitation, depression, sepsis, hypertension, and a history of cerebral infarction. The resident's family member initially requested the medical records via email, followed by a second email one week later, but did not receive a response from the facility regarding the process for obtaining the records. Staff interviews revealed that the Social Service Designee (SSD) was unaware of the request until after returning from vacation, and the Administrator had not been notified of the request at all. Facility policy required that requests for records be referred to the DON, Administrator, or another designated staff member, with records to be provided within two days after payment. The lack of response and failure to follow policy resulted in the deficiency.