Failure to Document and Track Medical Records Requests
Penalty
Summary
The facility failed to maintain a documented process for tracking medical records requests, resulting in a deficiency related to a resident's right to access personal medical records. Specifically, a legal representative for a resident with diagnoses including cellulitis, chronic kidney disease, and type 2 diabetes mellitus submitted a request for the resident's medical records. Upon review, it was found that the facility's log for tracking such requests had not been updated since a prior date, and the current request was not recorded. Interviews with the Medical Records Director and two Medical Records Assistants revealed that staff were either unaware of the log or had not used it, and instead relied on making copies and keeping email or fax confirmations as proof of completion. Further review of the facility's policy and procedure for resident access to protected health information indicated that all requests should be documented on a specific log, including the date of request, the staff member handling the request, and the date of the facility's response. The Administrator confirmed that the process was not being followed, and staff were not knowledgeable about the required documentation process. This failure to document and track medical records requests had the potential to delay the provision of requested documents to residents or their representatives.