Failure to Timely Provide Resident Medical Record to Legal Representative
Penalty
Summary
The deficiency involves the facility’s failure to provide a resident’s medical record to the resident’s Power of Attorney/Healthcare Representative (POA/HCR) in a timely manner after a formal request was made. The medical records staff member (V5) acknowledged receiving a request from the resident’s POA in October 2025, along with a completed application and identification. V5 stated that additional documents were needed to process the request and that attempts to reach the POA by phone were unsuccessful. Despite this, no certified letter or other documented follow-up was sent to inform the POA of the missing documents, resulting in the requested records not being provided. The resident’s admission record dated 1/20/2026 shows diagnoses including chronic ischemic heart disease, heart failure, renal dialysis, and pressure ulcers. The record also reflects a State of Illinois compliant authorization for release of patient information dated 10/1/2025 and a request for information dated 1/20/2026. The facility’s Medical Record Policy states that an organized, accurate, and complete written record will be maintained for each resident in accordance with applicable state and federal guidelines and that records are to be readily accessible. Despite this policy, the resident’s records were not made accessible to the POA/HCR as requested, leading to the cited deficiency.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.