Failure to Provide Timely Access to Medical Records for Resident's Legal Representative
Penalty
Summary
The facility failed to provide a resident's legal representative with access to the resident's medical records as required by policy. The resident in question had a history of multiple medical conditions, including cerebral infarction, congestive heart failure, type 2 diabetes, and atherosclerotic heart disease. After the resident was discharged, the resident's daughter, acting as a surrogate decision maker, requested access to the medical records. She provided a surrogate decision form, which the facility accepts as valid documentation for releasing records. However, the Medical Records Director did not release the records, citing the absence of a power of attorney (POA) document, and referred the matter to the corporate office for review. Despite the surrogate decision form being provided and accepted by facility policy, the records were not released in a timely manner. The Medical Records Director assumed the corporate office had reviewed the attached surrogate form, but it appears only the first page was reviewed, and the form was overlooked. The legal representative did not receive the requested records until months later, after further review during the survey process. The delay was due to miscommunication and failure to properly review and act on the provided surrogate documentation.