Failure to Provide Medical Records to Resident's Health Care Agent
Penalty
Summary
The facility failed to ensure a resident's rights regarding access to medical records were maintained when the resident's Health Care Agent (HCA), whose authority had been activated, requested copies of the resident's medical documentation. The HCA submitted a signed release form and made multiple requests for the records, both in writing and by phone, but did not receive the requested documentation. The facility's Medical Record Request log confirmed that requests were made on two separate occasions, but there was no indication that the records were provided. The resident involved had significant medical conditions, including Alzheimer's Disease, urinary tract infection, urinary retention, a history of falls, congestive heart failure, and malnutrition, and was assessed as severely cognitively impaired. Despite the facility's policy allowing residents or their representatives to obtain copies of records with proper notice and documentation, there was no evidence that the facility fulfilled the HCA's requests. The administrator confirmed that there was no documentation to support that the records had been provided as required.