Failure to Provide and Explain Access to Medical Records Upon Request
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.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A facility failed to timely release a resident’s medical records to the resident’s representative. The resident had fractures of the right fibula and left calcaneus, and the records request was held up with the facility’s legal team while the family was not informed of the delay.
A facility failed to provide a resident’s medical records within the required timeframe after a law firm requested them for litigation. The requestor reported repeated calls and emails with no response or records released, while staff gave inconsistent accounts of who handled record requests; the current administrator confirmed no records had been sent and that the facility lacked a designated person for this task.
A resident with severe cognitive impairment, dementia, and significant assistance needs had a representative repeatedly request copies of the full medical record, but the facility did not release them. Emails showed ongoing back-and-forth with the Administrator about consent, even though a health care representative document authorized the named individuals to request and receive medical information, and the resident had already been documented as unable to comprehend discharge information.
Failure to Provide Requested Itemized Bill: A cognitively intact resident repeatedly requested an itemized bill after discharge, but the BOM did not send it to the resident. The BOM said she requested the bill from a third-party billing system and received it later, but instead of providing it to the resident, she sent it to the resident's insurance company and kept no log of the request.
The facility failed to provide requested medical records to two residents or their representatives within the required timeframe. One cognitively intact resident with DM and CAD requested paper copies, but staff delayed release while discussing HIPAA paperwork, charges, and internal review; the records were not provided until weeks later. Another resident with COPD and dementia had a representative request records after a fall, but the request was routed through corporate compliance and delayed pending proxy authorization before the records were finally released.
Failure to Provide Requested Medical Records: The facility did not ensure a resident's medical records were available when requested by the family. The resident had chronic respiratory failure, HF, anxiety, and depression, and staff interviews showed the request was not passed along after the prior medical records clerk left. An LPN could not produce an email request, and the SSD confirmed the family was directed to the former clerk, who did not relay the request to the Clinical Manager.
Delayed Release of Resident Medical Records
Penalty
Summary
The facility failed to release medical records to a resident or the resident’s legal representative in a timely manner for Resident #101, resulting in delayed access to the resident’s medical records. Resident #101 was admitted with diagnoses including fractures of the right fibula and left calcaneus. The resident’s family member submitted an authorization for release of health information, signed by the resident, requesting the records, but the facility did not contact the family regarding the request for an extended period. During interview, the Nursing Home Administrator reported that the request had been received but was held up with the facility’s legal team, and the family was not informed of the delay until the day of the interview.
Failure to Release Requested Medical Records
Penalty
Summary
The facility failed to follow its policy to provide medical records within 30 days of a request for one resident. The resident’s record showed an admission date of 1/26/26 and discharge date of 2/5/26, with diagnoses including pneumonia, respiratory syncytial virus, NSTEMI myocardial infarction, atherosclerotic heart disease, chronic kidney disease stage 3A, hyperlipidemia, sepsis, heart failure, hypertensive heart and chronic kidney disease, unspecified atrial fibrillation, anemia, cognitive communication deficit, unspecified fall, and laceration with foreign body of the scalp. A medical record retrieval specialist for a law firm stated she requested the resident’s records on 4/6/26 and did not receive a response. She reported repeated follow-up calls and emails on 4/13/26, 4/18/26, 4/21/26, 4/27/26, 5/4/26, 5/11/26, 5/12/26, 5/19/26, 6/1/26, 6/4/26, 6/16/26, 6/18/26, and 6/25/26, but said she never received the records or any status update. She stated the request was for litigation purposes and that litigation was ongoing. Facility staff gave inconsistent accounts of how medical record requests were handled. The receptionist recalled receiving a request and said she forwarded it to the former administrator, who was responsible for medical record requests. The former DON stated she was not responsible for handling such requests and transferred calls to the front desk. A former medical records staff member stated records were typically gathered and released by the CEO within 30 days of receipt. The current administrator stated the facility did not have a designated staff person assigned to handle medical record requests, was not aware of the prior process, and confirmed that no records for the resident had been released or sent to the requestor.
Failure to Release Requested Medical Records
Penalty
Summary
The facility failed to ensure that Resident #99’s resident representative was provided copies of the resident’s medical record upon request. Resident #99 was admitted with diagnoses including a left chest wall contusion, acute embolism and thrombosis of the right lower extremity, and dementia with severe anxiety. The hospital discharge summary described the resident as severely cognitively impaired and needing moderate to extensive assistance with washing, dressing, toileting, transfers, ambulation, and meal cueing, and the record also noted that no nursing admission assessment or MDS had been completed at admission. The resident’s care plan and physician orders addressed nutrition, assistance with mobility and ADLs, therapy evaluations, and pressure injury prevention measures. Social work and psychiatric documentation later described severe cognitive impairment, confusion, disorientation, anxiety, and depressed mood. Nursing notes indicated that Person #1 signed discharge paperwork because the resident could not comprehend the discharge information. Person #1 stated that multiple requests had been made for the full medical record and that emails had gone back and forth with the Administrator without the records being sent. Person #2 stated that she had told the facility to send the records and believed written consent had been provided, but the request had been pending since December 2025. Email correspondence showed repeated requests for the entire record, while the Administrator responded that either Person #2 or the resident needed to sign consent because the resident was considered his/her own person. The facility also had a document naming Person #1 and Person #2 as health care representatives with authority to request and receive medical information, but the Administrator stated the records were not sent because the document was viewed as a living will only effective if the resident was deemed incapacitated.
Failure to Provide Requested Itemized Bill
Penalty
Summary
The facility failed to provide copies of an itemized bill as requested for 1 of 3 sampled residents, Resident #4. After discharge from the facility, Resident #4, who had a BIMS score of 15 indicating cognitive intactness, stated she called the facility on four different occasions after receiving statements from her insurance company and requested an itemized bill of services. She reported speaking with the receptionist twice and being transferred once to the billing person, who told her the bill would be available the next day, but when she called back she was told it was not ready and that a message would be given to the billing person. Resident #4 stated she never received the requested itemized bill. During interview, the Business Office Manager stated she would normally print the itemized bill and provide it to the resident, or request it from the third-party billing system and then print it for the resident. She stated that for discharged residents she would get an email address and send it by email or mail. She also stated she did not keep a log or documentation of requested items. When reviewing the request for Resident #4, the Business Office Manager found emails showing the resident called and requested the itemized bill to discuss with her insurance company, that she requested it from the third-party billing company, and that after receiving it she sent it directly to the resident's insurance company rather than to the resident. She stated, "Oh . that's on me. I never sent it to her," and stated there was no written process or policy related to provision of requested items from the business office.
Delayed Release of Resident Medical Records
Penalty
Summary
The facility failed to ensure that residents and their representatives were provided copies of health care records within two working days after a written request and advance notice to the facility. This deficiency involved two residents out of the sample reviewed: one resident requested medical records and did not receive them until about two weeks later, and another resident’s representative requested records and did not receive them until more than two weeks later. The facility policy stated that clinical information should be released in a timely manner, within two business days. Resident #15 was cognitively intact and had diagnoses including diabetes mellitus and coronary artery disease. The resident requested medical records and presented a completed request form to the surveyor, but there was no documented evidence that the records were provided within two working days. A care plan note documented that the resident requested a copy of medical records and was given HIPAA consent paperwork to sign, while the social worker stated the resident never returned the form. Other staff stated the resident requested paper copies, was told there could be a charge for a large amount of paper, and that the records were ultimately given on 06/09/2026 after the request on 05/25/2026. Resident #117 had diagnoses including COPD and dementia, and the MDS documented moderately impaired cognition with the representative participating in assessment. The representative requested medical records after a fall and stated they received them about a month later. Staff stated the request was routed through corporate compliance and that a health care proxy authorization was needed before release; the administrator stated the request was received on 05/29/2026 and the records were picked up on 06/15/2026 after the representative said they did not have the proxy authorization. The facility’s process described multiple internal approvals before release, and staff gave differing time frames for how long the request should take.
Failure to Provide Requested Medical Records
Penalty
Summary
The facility failed to ensure resident medical records were available upon request for one resident, Resident #72, who was admitted with diagnoses including chronic respiratory failure, heart failure, anxiety, and depression and was later discharged from the facility. Review of the closed medical record, interviews, and facility policy showed that the resident's family had asked for medical records, but the request was not provided to the staff member then handling medical records after the previous clerk left the facility. During interviews, the Clinical Manager stated she had started in the medical records office after the previous clerk left and had not been informed that Resident #72 wanted a copy of the records. An LPN stated she had corresponded with the family by email but could not provide an email showing a request for records, and said the request may have gone to the prior clerk who had not kept other staff updated. The SSD stated the family member asked for records and was told to speak to the previous medical records clerk, who did not relay the request to the Clinical Manager. The facility policy stated it would ensure timely, compliant access to residents' clinical records while protecting confidentiality and record integrity.
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