Failure to Provide Timely Access to Resident Medical Records
Penalty
Summary
The facility failed to provide a resident's medical records to the resident's Power of Attorney (POA) in a timely manner after a formal request was made. According to the facility's Resident Rights Policy, residents or their legal representatives are entitled to access or obtain copies of their personal and medical records within 24 hours (excluding weekends and holidays) for access, and within two working days for copies, upon request. In this case, the POA submitted a written request for the resident's complete medical chart, admission documentation, care plans, and a final billing statement to the Business Office Manager, who then forwarded the request to the DON. Despite this, the POA did not receive the requested records within the required timeframe. Interviews and documentation confirmed that the POA had not received any of the requested medical records even after several days had passed. The Administrator acknowledged that the facility's policy was not followed by the Business Office Manager and that both the Medical Records staff and the Administrator should have been informed of the request, not just the DON. The failure to provide the records as required by policy resulted in a deficiency related to resident rights and timely access to medical information.