Failure to Provide Medical Records to Resident's Legal Representative
Penalty
Summary
The facility failed to provide a resident's medical records to the resident's legal representative, despite a written request and the submission of the required Durable Power of Attorney (DPA) documentation. The DPA, dated 8/18/12, authorized the resident's family member to access healthcare and medical records. On 4/13/25, a formal written request for access to the resident's Protected Health Information (PHI) was submitted, specifying that the records be sent to the designated family member. The Medical Records Supervisor confirmed that the request was initially denied due to the absence of the DPA on file. However, even after the DPA was provided, the records were still not released to the family member. A review of the facility's policy and procedure on resident access to PHI indicated that all requests for access must be directed to the HIPAA Privacy Officer, who is required to allow inspection of records within 24 hours and provide copies within two working days of a written request. Despite these requirements, the facility did not provide the requested medical records to the resident's legal representative, as confirmed by staff interviews and record review.