Failure to Timely Release Resident Medical Records
Penalty
Summary
The facility failed to provide a resident and their legal representative with access to or copies of the resident's medical records within the required timeframe, despite a written request and proper authorization. The resident, who was cognitively intact and had significant medical conditions including a CRE infection, rectal cancer, and a colostomy, completed the necessary HIPAA authorization form to release their records to their Health Care Proxy. The facility's policy required that such requests be honored within 48 hours (excluding weekends and holidays) upon receipt of a written request. After the request was submitted, the process was delayed at multiple points. The Medical Records staff sent the authorization to Risk Management, which approved the release pending review by the DON. However, Medical Records did not forward the records for review until several days later, citing being off or occupied with other work. Complicating matters, the DON was no longer employed at the facility at the time, so the records were sent to the prior Administrator, but there was no follow-up or confirmation that the records were reviewed or released. As a result, the records were never provided to the resident or their representative. Interviews with staff revealed a lack of familiarity with the facility's policy on releasing medical records and a breakdown in communication and follow-up. Medical Records staff admitted they did not know the policy details and did not ensure the request was completed. The prior Administrator stated they would have expected to be notified sooner and that there should not have been a delay. Ultimately, the resident's request for their medical records was not fulfilled as required by facility policy and regulatory standards.