Failure to Provide Complete Medical Records Upon Resident Request
Penalty
Summary
The facility failed to ensure that a resident's request for access to and copies of her complete medical records was honored in a timely and comprehensive manner. The resident, who was cognitively impaired and required some assistance with activities of daily living, along with her elderly advocate, made multiple requests for her medical records, including medication and treatment administration records. Despite signing the required release form and following facility protocol, the resident and her advocate were repeatedly denied access to the full set of requested records. Staff interviews confirmed that the corporate compliance office directed them not to provide medication and treatment administration records, regardless of the resident's request or the completion of the release form. Facility policy stated that all information in the medical record could be released with written consent and that access should be provided within 24 hours, with hard copies available after 48 hours. However, the process involved sending the release form to the corporate compliance office, which then determined what records could be released. As a result, the resident did not receive all requested records, specifically the medication and treatment administration records, despite multiple attempts and clear communication of her needs. This deficiency was identified through medical record review, interviews with the resident, her advocate, staff, and review of facility policy.