F0573

D

Failure to Timely Fulfill Resident Medical Record Request

Fresno, California Survey Completed on 01-09-2026

Penalty

No penalty information released

Summary

The facility failed to fulfill a medical record request for one resident when it did not provide copies of the resident’s records after receiving a written request from a legal firm. The resident had been admitted with diagnoses including rhabdomyolysis, muscle weakness, and altered mental status, and was discharged after a 28‑day stay. A written request from an attorney’s office, dated 11/5/25, asked for production of all medical and billing records for this resident, stated that the office would contact the facility on or about 11/7/25, and requested production of the records on or before 11/14/25. On 12/16/25, surveyors observed the request form on top of the Medical Records Director’s desk with a sticky note reading “ASAP Need within five days! $.10 per page,” indicating it had not been processed.

During interviews, the Medical Records Assistant (MRA) stated this was her first week full‑time in the position, that she had been part‑time for the prior three weeks, and that there had been a Medical Records Director (MRD) in place from 10/30/25 until 12/2/25, during which time all record requests went to the MRD. The MRA reported she had not checked that pile of papers and was unaware of the exact timeframe in which the request needed to be filled, though she acknowledged it should have been completed per federal guidelines. The DON and Administrator each stated they did not know of a specific timeframe for completing record requests or a federal regulation setting such a timeframe. Review of the facility’s “Release of Information” policy showed that residents may access their records within 48 hours of a request and that non‑personal representatives such as legal firms may have access within 30 days of a written request, which had not occurred for this resident’s request.