Failure to Provide Timely Access to Requested Medical Records
Penalty
Summary
The facility failed to provide a resident with requested medical records within two working days following written requests, as required by regulation and facility policy. The resident, who had osteoarthritis of the knees, an anxiety disorder, and moderate cognitive impairment per the MDS dated 1/9/26, reported emailing multiple requests for medical records that were not fulfilled timely and stated she had to "hold staff's feet to the fire" to get anything done. On 1/22/26 after business hours, the resident emailed the Director of Rehabilitation (DOR) to follow up on previously requested medical records, specifically therapy records. The DOR notified the Medical Records Assistant (MRA) on 1/23/26, and the MRA documented receiving the request around noon that day and forwarding it to the legal department. The legal department responded at 4:37 p.m. on Friday when the MRA was out of the office, and the records were ultimately emailed to the resident by the DON on 1/27/26 at 4:46 p.m., exceeding the two-business-day timeframe. A second written request was emailed directly to the MRA on 2/5/26 at 11:51 a.m., using the resident’s own request format. The MRA documented that on 2/6/26 she went to the resident’s room and provided the facility’s authorization form for release of health information, which the resident accepted but stated she would complete when she had time, while asserting that the facility was violating federal law by not providing the records right away. The resident later emailed the completed authorization form on 2/9/26, backdated to 2/5/26, but the MRA noted it was not properly filled out when received. The MRA emailed the legal team for approval, received a response at 4:28 p.m. that the records could be released, and the records were emailed to the resident on 2/10/26. This second fulfillment also occurred more than two business days after the initial written request. The facility’s policy, revised 5/2017, states that residents may submit oral or written requests and may obtain copies of their records within two business days of such a request and completion of the authorization form, but in both instances the records were provided beyond the two-business-day requirement, resulting in delayed provision of medical records and decreasing the likelihood of the resident making informed medical decisions regarding her care.
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