Failure to Provide Resident Records to Legal Representative
Penalty
Summary
A deficiency occurred when the facility failed to provide a resident's legal representative with access to or copies of the resident's medical records upon request. The resident, who had multiple complex diagnoses including fractures, heart disease, dementia, and other chronic conditions, was admitted to the facility and had a power of attorney (POA) designated as his daughter. The facility's policy required that, upon receiving a valid request for medical records, the requesting party should be notified of the cost and records should be made available after payment is received. The policy also specified that records should be gathered and secured once a request is made. Despite these procedures, the resident's daughter/POA submitted a completed and signed request form for the medical records. However, the Medical Records staff member failed to recognize that the form had been filled out and, based on incorrect information from the previous Nursing Home Administrator, believed the form was incomplete. As a result, the request was not processed, and the records were not provided to the resident's representative. This failure was confirmed during the survey when the completed form was found in an envelope, unprocessed, and the staff acknowledged the oversight.