Failure to Timely Provide Medical Records to Legal Representative
Penalty
Summary
The facility failed to provide a resident's medical record to the legal representative in a timely manner, as required by facility policy and federal regulation. The legal guardian of a resident with multiple complex diagnoses, including intracranial hemorrhage, cerebral infarction, hemiplegia, bipolar disorder, depression, and anxiety, requested a copy of the resident's medical record during a care conference and through subsequent emails. Despite these requests, the guardian was not informed at the time of the initial request that a specific form needed to be completed, nor were they notified of any associated fees. The guardian made multiple attempts to obtain the records, both in person and via email, but did not receive the requested information within the required timeframe. Facility staff interviews confirmed that the process for requesting records required a form, but this was not communicated to the guardian at the time of the request. Additionally, staff did not inform the guardian of the potential fees for obtaining the records, and there was confusion regarding the ability to send records electronically. The medical records director acknowledged responsibility for processing such requests but did not provide the necessary information about fees or electronic delivery options. As a result, the legal representative was unable to access the resident's clinical information in a timely manner.