Failure to Provide Medical Records Upon Request
Penalty
Summary
A deficiency occurred when the facility failed to provide medical records upon request to a resident's responsible party (RP). The responsible party submitted a written request for access to the resident's protected health information, which was received by the Medical Records Director (MRD). Despite this, the MRD did not follow through with the request, resulting in a delay of at least 10 months without the records being provided or any update correspondence sent to the responsible party. The MRD acknowledged forgetting about the request and recognized that this was a violation of the resident's rights, as records are required to be provided within 30 days of the request. The resident involved had a history of chronic obstructive pulmonary disease (COPD), chronic diastolic heart failure, and ischemic heart disease, and was assessed as having moderately impaired cognition but retained the ability to understand and make decisions. The facility's policy and procedure for release of information required that records be transmitted within 15 calendar days after receiving a written request. The failure to provide the requested records in a timely manner was confirmed through interviews and record review, with the responsible party expressing feelings of distrust and concern due to the lack of response from the facility.