Failure to Provide Timely Access to Resident Records
Penalty
Summary
The facility failed to provide timely access to resident records upon request, affecting two residents who had requested their medical records or had requests made on their behalf. In the first case, a resident with intact cognition had an attorney request the entire electronic nursing home chart for estate purposes. Despite multiple written requests and follow-up communications, the records were not provided for over a month. Facility staff, including the medical records staff and the administrator, were uncertain about procedures for records from before a recent change in facility ownership. Staff communications with the regional legal department revealed confusion and delays, with instructions to wait for a subpoena before releasing records, and no clear direction on handling records from the previous ownership. The attorney eventually threatened to subpoena the records due to the lack of response. In the second case, a resident with impaired cognition requested all records, and a subpoena was later issued for the documents. The medical records staff confirmed that no records had been provided since the change in ownership and was unaware of the request or the requirement to provide records in a timely manner, even for residents admitted under previous ownership. Facility policy required that records be provided within two business days of a written or oral request, but this policy was not followed. The deficiency was identified through record review, staff interviews, and policy review, confirming that the facility did not comply with its own procedures or regulatory requirements for timely access to resident records.