Failure to Provide Policies and Procedures to Resident's Legal Representative
Penalty
Summary
The facility failed to comply with state regulations by not providing copies of its Policies and Procedures (P&P), as required by Title 22 California Code of Regulations section 72523, to the legal representative of a resident upon written request. The resident had been admitted and later discharged to an acute care hospital. A review of the admission record and the release of record log confirmed that the legal representative submitted a written request for all required administrative, management, personnel, and patient care policies. The Director of Medical Records (DMR) acknowledged receipt of the request and stated it was forwarded to the facility's Administrator (ADM) and legal team, but did not process the request for policy information. During interviews, the ADM stated unawareness of any requirement to release the facility's P&P to the public unless the request came from a court. The facility's own Medical Record Request Policy indicated that all requests for medical records, whether verbal or written, must be immediately forwarded to the Medical Records department or designated staff, including requests from residents or their personal representatives. Despite this policy, the facility did not release the requested P&P to the resident's legal representative.