F0573

D

Failure to Provide MPOA Timely Access to Resident Lab Results

Longview, Texas Survey Completed on 02-09-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure that a resident’s medical power of attorney (MPOA) had timely access to the resident’s medical records, specifically urinalysis (UA) lab results, as required by resident rights regulations. The resident was an older male with a history of cerebral infarction affecting the right middle cerebral artery, dementia without behavioral disturbance, hemiplegia and hemiparesis of the left non-dominant side, cognitive communication deficit, and seizures. His care plan documented impaired cognitive function and dementia, with interventions that included communicating with family/caregivers regarding the resident’s capabilities and needs. A quarterly MDS showed severe cognitive impairment with a BIMS score of 0/15, unclear speech, and dependence or maximal assistance for most ADLs, indicating that the resident relied on his MPOA to act on his behalf.

The resident’s medical power of attorney document, dated 1/6/23, appointed a family member as the Agent under Texas law and explicitly authorized the Agent, as the resident’s HIPAA personal representative, to request, receive, and review all medical and hospital records and other protected health information. In December 2025, multiple laboratory specimens were collected for the resident, including on 12/24/25, when a UA related to a UTI was obtained. The MPOA verbally requested the resident’s UA lab results from facility staff, including from the medical records staff and an LVN. According to interviews, the LVN reported she had been instructed not to provide any medical information directly and to direct all such requests to medical records via a release form, regardless of whether the request was for a verbal explanation or a hard copy of records. The MPOA stated she was denied verbal results by the LVN and never received the lab results.

The medical records staff member confirmed that the MPOA verbally requested the UA results in December 2025 and that she provided a medical records release form, explaining that facility policy required completion of the form before any records could be released. She stated she did not receive the completed form and therefore did not provide the requested documents. A subsequent letter from a family member to medical records requested an explanation for the denial of the resident’s recent test results, and the company’s legal department responded that, under 45 C.F.R. § 164.524(b)(1), they could require written requests and that no written request from the MPOA had been received. The facility’s Release of Medical and Billing Records Policy required a fully completed authorization form and routing all requests through the legal department before releasing any information. As a result of these practices and requirements, the resident’s MPOA was not given access to the resident’s UA lab results within 24 hours of request, and copies were not provided within two working days, constituting a failure to honor the resident’s right to access records as specified in the regulations.