Failure to Provide Timely Access to Resident Medical Record
Penalty
Summary
The facility failed to provide a resident’s legal representative with timely access to the resident’s medical record after a written request. A complaint was received by the Office of Health Care Quality alleging that the facility did not provide a copy of the medical record when requested. Review of the resident’s clinical record showed the resident had been admitted on an earlier date and was deemed incapable of making all medical decisions by two physicians, with the resident’s mother identified by the DON as the legal representative. The facility’s Access to PHI policy requires that all requests for access or inspection be submitted in writing (or documented in writing by staff if made orally) and that the facility act on all requests within 48 business hours for current patients. During interviews, the DON initially stated that the resident’s representative could request and obtain copies of the medical record but must follow the facility’s process, and reported that there was no current medical record request on file for this resident. However, the Director of Medical Records later confirmed that the facility had, in fact, received a medical record request for this resident on a specific date, but that the family had not completed and returned additional facility paperwork. Despite the existing written request and the facility’s policy requiring action within 48 business hours, the record was not provided to the representative, leading to the cited deficiency.
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