Failure to Provide Timely Access to Requested Medical Records
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s right to timely access to personal and medical records. A male resident with unspecified dementia, moderate cognitive impairment (BIMS score of 09), type 2 diabetes mellitus, and acute pain due to trauma was admitted and later discharged from the facility. His care plan reflected impaired cognitive function related to dementia. After discharge, the resident’s responsible party (RP) completed and signed an authorization to disclose protected health information form requesting the resident’s medical records. On the date of the request, the Medical Records LVN received the RP’s request for the resident’s records and forwarded it to the Health Information Management (HIM) Director. The LVN reported that, because the family requested the entire chart, the HIM Director decided she would handle compiling and emailing the records directly to the RP. The LVN stated she typically provided records such as medication lists after clearance from the HIM Director, but in this case, the HIM Director took responsibility for sending the full chart. The LVN was unsure of the exact time frame required to send requested records and indicated she would need to review facility policy, though she believed records were usually sent timely. The HIM Director stated she had completed gathering the requested records and believed she had sent them via secure email, which normally generated a confirmation receipt. However, upon reviewing her email, she found no record of sending the resident’s requested records and no confirmation receipts. She acknowledged having multiple record requests at that time and could not locate any evidence that the records for this resident had been sent. The facility’s policy stated that residents have the right to access all records pertaining to their care within 24 hours of an oral request followed by a signed written request, and that requests to purchase copies of records would be granted within two working days. Despite this policy, the requested records were not provided to the resident’s RP as required.
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