Failure to Provide Timely Access to Resident Medical Records
Penalty
Summary
The facility failed to provide a resident and her representative with timely access to her personal and medical records upon request. The resident, who was cognitively intact and her own responsible party, had multiple diagnoses including type 2 diabetes mellitus with foot ulcer, chronic kidney failure, essential hypertension, chronic pain, muscle weakness, and urinary tract infection. Despite several written requests for her medical records sent by her representative, the facility did not provide the requested records within the required timeframe. Interviews with the facility's medical records staff revealed that the process for releasing records required completion of specific forms, notarization as applicable, and payment of any associated fees before records would be released. The staff member acknowledged receiving documentation requesting the records but stated that no payment had been received from the resident's representative. Furthermore, after being told by the representative not to call his phone number and to communicate through his appointed representative, the staff did not reach out to the appointed representative to resolve the matter. The facility's administrator was unaware of any unaddressed requests for records and indicated that all such requests were processed by the medical records staff. The facility's policy required validation of the request, notification of costs, and receipt of payment before releasing records, with a stated timeline of two days after payment. However, in this case, the resident and her representative were not provided with the requested medical records as required by regulation.