Failure to Provide Resident Records to Legal Representative
Penalty
Summary
The facility failed to provide medical records to a resident's legal representative as required. The resident, who had diagnoses including metabolic encephalopathy, epilepsy, vascular dementia, and major depressive disorder, was moderately cognitively impaired at the time of discharge. After discharge, the resident's daughter, who held power of attorney, completed and submitted a HIPAA-compliant authorization form requesting access to the resident's medical records. The form, which specified that the facility must act within 30 days, was handed to a social services staff member, who stated she placed it on the administrator's desk and notified her. Despite this, the administrator and the Vice President of Clinical Services both stated they had never seen the request form and were unaware of its submission. The social services staff member confirmed receiving the form and taking steps to forward it, but no further action was taken, and the records were not provided to the resident's legal representative. This lack of follow-through resulted in the facility's failure to meet the regulatory requirement to provide timely access to resident records.