Failure to Provide Timely Access to Requested Medical Record
Penalty
Summary
The deficiency involves the facility’s failure to provide timely access to a resident’s medical record after a written request. A resident with intact cognition, as evidenced by a BIMS score of 15/15 on an MDS assessment dated 12/10/25, had been admitted with diagnoses including acute and chronic respiratory failure with hypoxia and COPD with acute exacerbation, and was discharged on 12/10/25. The resident and a family member submitted a written request for the resident’s medical record to the Nursing Home Administrator via email on 1/20/26, followed by a signed formal request sent via email on 1/22/26. As of 2/5/26, the resident had not received the requested records. The family member reported that the NHA responded by email stating the facility had up to 30 days to provide the records. During interviews, the DON stated the facility did not have a policy for medical record requests and instead followed state and federal regulations. The Social Worker acknowledged awareness of the resident’s request but was uncertain of the required timeframe for releasing records, estimating it to be 48 hours. The NHA showed the surveyor a paper copy of the resident’s medical record and stated that a meeting to review the records, originally planned for 2/4/26, had been postponed to 2/6/26, and that the NHA intended to call the resident after the meeting to inform them the records were ready for pickup. Despite the request and internal awareness of it, the records had not been provided to the resident within the required timeframe, resulting in the deficiency related to timely access to medical records.
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