Failure to Timely Provide Resident Records and Facility Documents
Penalty
Summary
The facility failed to provide a copy of a resident's medical record and related facility documents to the resident's legal representative within the required two working days after receiving a valid request. The legal representative, acting through a law firm, submitted a written and signed authorization for the release of the resident's medical records, billing records, photographs, charts, admission agreements, utilization review committee records, x-rays, facility resident care policies, and posted nurse staffing data for the previous eighteen months. Despite multiple follow-up attempts by the legal assistant via phone and email, the facility did not provide the requested records until 13 days after the initial request was received. The resident in question had moderately impaired cognitive function and had a designated representative with power of attorney for health care. The Director of Medical Records confirmed receipt of the request and verified the authorization but acknowledged that the records were not provided within the regulatory timeframe. The facility also failed to provide the daily posting of the staffing record and resident care policies as requested. The DON was informed of these findings and acknowledged the delay.