Delay in Providing Medical Records to Authorized Family Member
Penalty
Summary
The facility failed to provide a requested medical record for a discharged resident within two days of a written request, as required. The family member of a resident with severe cognitive impairment, as indicated by a BIMS score of 3 and diagnoses including Alzheimer's Disease, Dementia, Respiratory Disorder, and COPD, submitted a written request for the resident's medical records. The family member was listed as the primary contact and designated with full PHI access. The request was received by the facility and forwarded to the contracted provider, who responded the same day that additional documentation was needed to confirm the requestor's authority. Despite receiving this information, the facility did not promptly communicate the need for additional documentation to the family member. The Administrator waited approximately two weeks before informing the family of the requirement for further documentation, resulting in a delay that exceeded the two-day regulatory timeframe. The deficiency was identified through interviews, record reviews, and examination of facility documentation, and was specific to the handling of this single resident's record request.