Failure to Provide Timely Access to Resident Medical Records
Penalty
Summary
A resident with a diagnosis of polyneuropathy and a BIMS score indicating cognitive intactness requested access to her complete medical records on multiple occasions via email to the Medical Records department and the Director of Nursing. The resident initially received only psychiatric notes after her first request, but subsequent requests for her full medical record, made on several dates, were not fulfilled. The resident also did not receive responses to her follow-up emails regarding these requests. Interviews and record reviews confirmed that the Medical Records staff received the resident's requests and were aware of the facility's policy requiring provision of records within 48 hours, excluding weekends and holidays. Despite this, the staff did not provide the requested records or respond to the resident's repeated communications. The Medical Records staff could not provide a reason for the lack of response or the failure to release the records, and the administrator acknowledged that the policy was not followed.