Failure to Timely Release Resident Medical Records Upon Request
Penalty
Summary
The facility failed to ensure that, upon written request, a resident's medical records were released within the required timeframe. A resident who had been admitted and later discharged with a diagnosis including aftercare following surgical amputation submitted a written request for copies of nursing progress notes for personal use. The request was signed and dated by the resident. The facility's Released Records Log indicated that the request was made, but there were no further notations regarding the records being provided or picked up until several months later. An internal electronic communication from the facility's legal analyst noted that the resident had severe cognitive impairment and stated that the resident's wife would need to sign the request form for the records to be released. However, there was no documentation that the resident's representative was notified of this requirement. Interviews with the Medical Records Director (MRD) and the Director of Nursing (DON) confirmed that the process for releasing records involves verification, legal department approval, and release within two business days. The MRD acknowledged that after forwarding the request to the legal department, there was no follow-up with the resident's wife when she did not arrive to pick up the records, and the records were not provided within the required timeframe. The DON also confirmed that the records should have been provided within two business days of the request, as per facility policy.