F0573

D

Failure to Provide and Explain Access to Medical Records Upon Request

Whittier, California Survey Completed on 03-26-2026

Penalty

No penalty information released

Summary

The facility failed to provide and explain the process for obtaining a copy of a resident’s medical records upon request, in accordance with its policy on Protected Health Information. A resident with Type 2 DM and dementia was admitted in early February, and an IDT care plan review was conducted later that month, authored by the Social Service Assistant (SSA) and attended by an RN, rehabilitation staff, the Activity Director (AD), the resident, and the resident’s responsible party (RP). The IDT documentation did not include the topics discussed during the meeting and was not signed and dated by the SSA. During this IDT meeting, the RP requested the resident’s medical records, and the SSA verbally stated she would obtain the records, but no documentation of this request or follow-through was made.

Following the meeting, the RP waited several weeks without receiving the records and repeatedly called the facility to follow up. The receptionist reported the SSA was unavailable and did not connect the RP with another staff member who could assist. After multiple attempts, the RP was eventually transferred to the Medical Records Director (MRD), who stated she had not been informed of the earlier request and told the RP that a request form needed to be completed. The MRD reported that the SSA, who no longer worked at the facility, had not communicated the RP’s request from the IDT meeting. The AD confirmed being present at the IDT meeting and recalled the RP asking for the records and the SSA stating she would get them. The facility’s policy stated that a resident may have access to records within 24 hours of a written or oral request, excluding weekends and holidays, but this process was not followed or explained to the RP.