Failure to Provide Medical Records Upon Request
Penalty
Summary
The facility failed to provide copies of medical records to the responsible party of a resident upon repeated requests. The resident, who was admitted with muscle wasting, atrophy, lack of coordination, and generalized muscle weakness, did not have cognitive impairments and required substantial to maximal assistance with mobility. The responsible party made multiple requests via email to various facility staff, including the Business Office Manager, Social Services Director, Administrator, and Medical Records Director, specifically asking for copies of documents signed by the resident, such as the Notice of Medicare Non-Coverage (NOMNC). Despite these requests, there was no response or provision of the requested records. Interviews with facility staff confirmed that the emails were received by the relevant personnel, but no action was taken to fulfill the requests. The Medical Records Director stated that she was instructed by the Administrator in Training not to respond to the responsible party's emails. The Social Services Director and Business Office Manager also acknowledged receipt of the requests but did not provide the records or follow up to ensure the request was addressed. The facility's policy required providing access to or copies of records within 24 hours, but this policy was not followed in this instance.