Failure to Provide Timely Access to Resident Medical Records
Penalty
Summary
The facility failed to provide a resident with access to her medical records upon request, as required by policy and regulation. A resident, who had no cognitive impairment, and her sister contacted the facility's medical records staff to request a copy of the resident's medical records. The staff member, who was newly assigned to the medical records role and had limited training, was unsure if residents or their families were permitted to obtain copies of records and believed only insurance companies could do so. The staff member sought clarification from corporate leadership and the DON, who confirmed that residents and their families have the right to access records, but did not follow up with the resident or her sister in a timely manner. The facility's policy states that residents or their legal representatives are entitled to access their records within 24 hours of a request and to receive copies within two working days. Despite this, the resident and her sister did not receive the requested records or a return call from the medical records staff, resulting in a failure to meet the required timeframe and to honor the resident's rights.