Failure to Provide Timely Access to Resident Medical Records
Penalty
Summary
The facility failed to provide timely access to medical records to a resident's legal representative as required by regulation and facility policy. The facility's policy dated 12/02/2025 stated that residents could request access to their medical information orally or in writing, and that such requests would be submitted in a timely manner to the corporate compliance vendor for approval and tracking. Resident #3, who had diagnoses including anxiety, bipolar disorder, repeated falls, and severe cognitive impairment per a 06/05/2023 MDS, was discharged home on hospice on 07/27/2023. After the resident's death, the family requested medical records. On 03/25/2025, the Director of Medical Records sent the family an authorization form, and on 04/07/2025 the family returned the completed authorization form and death certificate. Despite receipt of the completed request on 04/07/2025, the Director of Medical Records did not submit the request and supporting documents to the third-party corporate compliance company until 04/24/2025. The Director of Medical Records acknowledged that the request may have been missed or not handled timely due to competing responsibilities, which included scheduling appointments, referrals, transportation, managing provider dictations, scanning and uploading external records, and other medical records duties. The Director also believed records requests needed to be completed within 30 days, rather than the regulatory requirement of two working days for access. The Administrator stated that the Director of Medical Records was responsible for medical records requests and that staff would forward any such requests to that individual. The delay from 04/07/2025 to 04/24/2025 in submitting the request to the third-party company resulted in the resident's legal representative not receiving access to the medical records within two working days of the written request, in violation of 10 NYCRR 415.3(c)(1)(iv).
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