Failure to Timely Provide Requested Medical Records to Resident’s Representative
Penalty
Summary
The deficiency involves the facility’s failure to provide timely access to a deceased resident’s medical records to the resident’s Responsible Party (RP), as required by regulation and facility policy. The resident was admitted and later discharged due to death, and after the resident’s death the RP initiated multiple attempts to obtain the resident’s medical records. The RP first submitted a medical records request by certified mail, which tracking showed was delivered, and also sent an email to the facility’s Social Services Director (SSD) asking for assistance with the process and what documents were needed. The RP reported making multiple phone calls without connecting with the appropriate staff. When the RP did not receive a response, she sent a follow-up request and supporting documents via fax to the facility’s Medical Records Department, addressed to the Medical Records staff by name, and obtained a fax confirmation report showing successful transmission. The faxed packet included a cover letter referencing the earlier certified mail request and asking the facility to confirm receipt, along with a completed authorization for release of information, a copy of the resident’s death certificate, and a copy of the RP’s government-issued ID. Despite these documented efforts, the facility did not respond to the RP’s direct requests. Interviews and record review showed that the Medical Records Director (MRD) and the Administrator were not aware of the RP’s earlier certified mail and fax requests and only processed a later request submitted by a law firm on behalf of the RP, at which point the records were released. The MRD stated that the facility receives many faxes on two fax machines and the RP’s faxed request could have been mixed with other documents. The SSD acknowledged receiving an email from the RP requesting help with obtaining records and stated she must have overlooked it, noting that “it seems this one slipped by.” The MRD confirmed that, per facility policy, medical records requests should be fulfilled within 24 hours (excluding holidays and weekends), and acknowledged that the RP did not receive the requested records in a timely manner, contrary to the policy and regulatory requirements for resident access to records.
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