Failure to Provide Timely Access to Medical Records
Penalty
Summary
The facility failed to provide a resident with requested medical records in a timely manner. The resident, who had diagnoses including myopathy, inflammatory and immune myopathies, leg pain, anxiety, atherosclerotic heart disease, and a history of falls, made multiple requests to the Director of Rehab for therapy medical records. Despite assurances from the Director of Rehab that the records would be provided, the resident did not receive them. The resident also submitted a written request for medical records to the Administrator, who did not fulfill the request after being informed by the Business Office Manager that the resident allegedly no longer needed the paperwork. Further interviews revealed that the Business Office Manager had spoken with the resident, who clarified that she wanted paper copies of her medical records to provide to her attorney and did not wish to review them with staff. The Business Office Manager documented this request and communicated it to the Administrator, but was waiting for the Administrator to provide the records. The Director of Rehab, after consulting with her supervisor, deferred the request to the facility and did not inform the resident of the proper procedure. As a result, the resident's request for medical records was not fulfilled in a timely manner.