Failure to Provide Timely Access to Requested Medical Records
Penalty
Summary
The facility failed to provide timely access to a resident’s medical records as required by its policy and procedure titled Access to Personal and Medical Records. One resident, originally admitted and later readmitted to the facility, had diagnoses including muscle weakness and difficulty walking. A History and Physical dated 1/9/2026 documented that the resident had fluctuating capacity to understand and make decisions, while a Minimum Data Set (MDS) dated 10/14/2025 indicated the resident was usually able to understand and be understood by others. The MDS further showed the resident required supervision for eating and oral hygiene, was dependent for toileting hygiene, showering/bathing, lower body dressing, and footwear, required maximal assistance for upper body dressing, and moderate assistance for personal hygiene. On 12/23/2025 at 11:15 a.m., the resident’s attorney’s office contacted the Medical Records Director (MRD) to request the resident’s medical records, followed by an email at 4:10 p.m. the same day, for which no confirmation was received. The attorney later spoke with the MRD on 1/8/2026 and was informed that the MRD was waiting for supervisor verification before releasing the records. In a subsequent interview, the MRD stated she received the written request on 12/23/2025 after 4:00 p.m. but did not send the records because the corporate office had to review them first and had told her she had a month to send them. On 1/26/2026, the MRD acknowledged that more than 30 days had passed since the request and confirmed that the facility’s policy required that requested medical records be provided as soon as practicable within 5 days, up to 30 days from the date of the written request. This delay resulted in the facility’s failure to release the resident’s medical records within 30 days, violating the resident’s and resident representative’s rights to access records.
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