Failure to Provide Timely Access to Resident Medical Records
Penalty
Summary
The facility failed to ensure that a resident's representative was provided access to and copies of the resident's medical records as requested. The representative initially requested the records in February, and after being asked to complete an Authorization for Release of Information, returned the completed form in early March. The Health Information Manager (HIM) forwarded the request to the facility's legal team, which approved the release of the records. However, due to a breakdown in communication, the HIM was not included in the legal team's email response approving the release, and as a result, the records were not sent to the resident's representative. Interviews with facility staff, including the HIM, Social Worker (SW), Director of Nursing (DON), and Administrator (ADM), revealed confusion regarding the status of the request and a lack of follow-up to ensure the records were provided. The facility's policies did not specify procedures or time frames for processing medical record requests, nor did they clearly state the resident's right to receive copies of medical records. The resident involved had severe cognitive impairment and was at risk for impaired cognitive function, making timely access to records by the representative particularly important.