Failure to Provide Timely Access to Requested Medical Records
Penalty
Summary
The deficiency involves the facility’s failure to provide a resident timely access to and copies of her medical records as required by facility policy. The resident was admitted with multiple diagnoses including obesity, acute respiratory failure without hypoxia, basal cell carcinoma of the right upper limb/shoulder, unilateral primary osteoarthritis of the left hip, and muscle wasting and atrophy. An initial history and physical documented that the resident had capacity to understand and make decisions. The facility’s written policy, revised in May 2017, stated that residents must be provided access to their personal and medical records within 24 hours (excluding weekends and holidays) of request, and copies of records within two business days of an oral or written request. Record review showed that the facility received written Authorization for Use or Disclosure of Protected Health Information forms from the resident on multiple occasions. Requests dated 3/6/2025 and 4/4/2025 were fulfilled by the facility on 3/26/2025 and 4/14/2025 respectively, which exceeded the two-business-day timeframe in the policy. An email from the resident dated 6/23/2025 requested release of medical records, but the facility did not release the records in response to that request. Another authorization form dated 7/1/2025 was received without the resident’s signature, and the facility did not provide copies of the records at that time. The administrator later acknowledged that the 6/23/2025 request was not honored. During interviews, the administrator and Director of Medical Records described a practice of varying response times based on the volume of records requested, stating that small requests could be completed the same day, while large requests could take several days. The administrator stated that on 3/6/2025 and 4/4/2025 the resident requested a large volume of records and that the medical records department might need more than two days, and would tell residents they needed more than the 48 hours indicated in the policy. The Director of Medical Records stated that staff visit residents to help complete consent forms, that residents are informed how long it may take and asked about preferred format, but also stated that medical records staff do not document these visits in the resident’s record. The resident reported having requested records multiple times by email and phone without success, refused to sign the release form because it released the facility from liability, and stated that the medical records staff member never told her how long it would take to receive the records. The surveyors concluded that the facility failed to provide copies of requested medical records within two business days as required by its own policy, thereby violating the resident’s right to obtain records in a timely manner.
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