Failure to Provide Medical Records to Legal Representative After POA Activation
Penalty
Summary
A deficiency occurred when the facility failed to provide a resident's medical records to the resident's legal representative after a written request was made. Initially, the resident was responsible for their own decisions, and the family member's request for records was denied because the Power of Attorney for Health Care (POAHC) had not yet been activated. The facility's policy required a properly executed authorization from the resident or their legal representative for release of records. The family member signed an authorization form, but it was not valid since the resident had not authorized it and was in the hospital at the time. Subsequently, the resident's POAHC was activated, naming the same family member as the legal representative. Despite this change in status, the facility did not revisit or act upon the original request for medical records. Interviews with the POAHC agent and the Nursing Home Administrator confirmed that the request remained unaddressed after the POAHC was activated, and no records were provided to the legal representative. The resident had diagnoses including End Stage Renal Disease, altered mental status, and a stage 4 sacral pressure ulcer at the time of the incident.