Failure to Provide Complete Medical Records Upon Request
Penalty
Summary
The facility failed to provide a complete set of medical records to a complainant who had requested them multiple times for a specific resident. Record reviews confirmed that only partial records were sent on two separate occasions, with 9 pages (including a cover page) faxed on one date and 14 pages (including a cover page) faxed on another. Despite repeated requests, including a formal letter requesting all medical records from the patient chart, there was no documentation or fax confirmation that the full medical record had ever been provided to the complainant. Interviews with facility staff revealed uncertainty regarding whether the complete medical record packet was ever sent. The medical records staff member was unable to confirm the transmission of the full records and needed IT assistance to retrieve email records, which were not immediately available. The DON later confirmed that only incoming emails had been retrieved, and there was no confirmation of outgoing emails to verify that the complete records were sent. As a result, the surveyor determined that the facility did not ensure timely and complete access to the resident's medical records as required.