Failure to Provide Timely Access to Resident Medical Records
Penalty
Summary
The facility failed to provide a copy of a resident's medical records upon written request, violating the resident's right to access their own records. The resident, who had a history of hemiplegia, hemiparesis following cerebral infarction, altered level of consciousness, hypertension, diabetes mellitus, and stroke, was discharged to another facility at the family's request. The resident's legal representative submitted a written request for the medical records, which was personally served to the Medical Records Director (MRD). Despite the facility's policy stating that records should be provided within 24 to 48 hours of a completed request form, the MRD sent the request to the facility's attorney for review several days after receipt. The process also required approval from the Director of Nursing before release. As of the date of the interview, the complainant had not received any records. The facility's policies confirmed the resident's right to access and obtain copies of their records with appropriate notice, but the records were not provided as required.