Failure to Provide Timely Access to Resident Medical Records
Penalty
Summary
The deficiency involves the facility’s failure to provide timely access to personal and medical records to a resident’s legal representative after a valid request. The resident was an elderly female with Alzheimer’s disease who had been admitted with that diagnosis and later had an unplanned discharge with anticipation of return. Her attorney, acting as her legal representative, sent a written request for records, including all correspondence with the Texas Health and Human Services Commission related to the resident’s Medicaid nursing facility benefits for the prior two years, as well as the daily plan of care, nursing logs, medication logs, incident reports, and any emails, letters, and notes related to the resident. A HIPAA Authorization to Disclose Protected Health Information, signed by the resident’s legal representative, authorized the attorney’s office to receive any and all information concerning treatment or services rendered to the resident. Despite this, the attorney reported during interview that she had still not received the requested records months after the initial request, and she confirmed with Medical Records and the Administrator that the request had been received. Interviews and document review showed that the facility did not follow an effective process to ensure the request was fulfilled within regulatory timeframes. The Medical Records staff stated that attorney requests were sent to the corporate office and the facility’s attorney and were not handled at the facility level; she acknowledged awareness of the request and said it had been sent to the Administrator before he went on leave. The facility’s attorney/Chief Operating Officer later stated that the record request had been “overlooked and missed.” The Regional Administrator reported that the records request had been sent directly to the attorney rather than to the designated medical records request email and that there was no process in place to monitor the request after it was forwarded. The facility’s Release of Information Protocol indicated that legal and personal requests should be sent to a specific Medical Records Request email for review and presentation to the facility’s attorney, but the monitoring and follow-through steps were not carried out, resulting in the resident’s legal representative not receiving the requested records as required.
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