Failure to Provide Timely Access to Resident Medical Records
Penalty
Summary
The facility failed to provide timely access to medical records for one resident, as required by its own policy. The policy stated that copies of a resident's medical record must be provided within two working days of a written request. In this case, the first documented request for records was received on 11/03/25, but the records were not released until 11/07/25, exceeding the required timeframe. The delay was attributed to the facility's belief that the resident lacked capacity and that the Advance Health Care Directive (AHCD) was invalid, despite documentation and statements confirming that the resident's family member was authorized to make medical decisions. The resident involved had diagnoses including essential hypertension, type 2 diabetes mellitus, and mild protein-calorie malnutrition, with a BIMS score indicating moderate cognitive impairment. Multiple requests for records were made by the resident's family, who had submitted both an AHCD and a Durable Power of Attorney to the facility. Both the Administrator and the Director of Nursing confirmed the delay and acknowledged that the records were not released within the required timeframe, despite recognizing the family member as the authorized decision-maker.