Failure to Timely Release Medical Records Upon Written Request
Penalty
Summary
The facility failed to provide a copy of a resident's medical records upon written request, violating the resident's right to access their own records. The resident, who had diagnoses including chronic obstructive pulmonary disease (COPD) and muscle weakness, had a record release request submitted by a law office on their behalf. The Medical Record Director (MRD) received the request and forwarded it to the facility's legal department, but did not release the records, believing she had additional time to fulfill the request. The MRD was still waiting for the nursing department to complete their section of the records and had not yet provided the requested documents. Interviews with facility staff revealed a lack of clear policy and procedure regarding the timeframe for releasing medical records. The Administrator and Director of Nursing (DON) both acknowledged that there was no specific policy guiding the release of records or the associated costs, and were unaware of the delay until it was brought to their attention by surveyors. The DON also indicated that requests for records typically go through the front office and administration, and he was not informed of the request until the day of the survey.