Failure to Timely Provide Medical Records to Legal Representative
Penalty
Summary
The facility failed to provide copies of a resident's medical records upon request and within the required two business days after receiving a request from the resident's legal representative. The resident, who had diagnoses including respiratory failure and type 2 diabetes mellitus, had been transferred to an acute care hospital and did not return. The legal representative, through an attorney, submitted a written request for the resident's complete medical records, including a signed authorization form. The Director of Medical Records (DMR) received the request and forwarded it to the facility's legal department, following the facility's usual process for requests from law firms or subpoenas. Despite the DMR uploading the resident's entire medical record to a secure link provided by the legal department, the records were not released to the legal representative within the required timeframe. Interviews with the DMR, Director of Nursing (DON), and Nurse Consultant revealed confusion regarding responsibility for fulfilling such requests, with the DMR and DON deferring to the legal department. The facility's policy indicated that non-personnel representatives, such as legal firms, should have access to records within 30 days of a written request, but the records were not provided within this period, resulting in the deficiency.