Failure to Provide Timely Access to Medical Records
Penalty
Summary
The facility failed to provide a resident with access to her medical records after multiple requests were made by both the resident and the New Mexico State Ombudsman acting on her behalf. The resident, who had diagnoses including anxiety disorder, major depressive disorder, and ADHD, requested her medical records in the first week of July from several staff members, including nurses, the DON, the Medical Records Director (MRD), and the Administrator (ADM). Despite these requests, the resident did not receive any part of her medical records, nor was she given a written explanation for the delay or denial. Documentation shows that the Ombudsman initially requested the records via email on July 1, with follow-up requests made in subsequent weeks. The facility's Health Information Management Manual states that requested copies should be provided within two working days, and that residents must receive a timely, written denial if access is denied. However, the records were not provided within the required timeframe, and no written denial was issued to the resident or her representative. Interviews with facility staff revealed confusion regarding what constituted the resident's medical record, particularly concerning pharmacy communications and medication information. The MRD and DON indicated that pharmacy information was not considered part of the medical record, and the ADM stated he was unaware of the initial request but expected records to be provided promptly. Despite these statements, the resident's requests remained unfulfilled, and the facility did not follow its own policy or federal requirements regarding access to medical records.