Failure to Timely Provide Complete Medical Records to Former Resident’s Representative
Penalty
Summary
The deficiency involves the facility’s failure to timely release a complete medical record for a former resident to the resident’s family and their legal representative, despite multiple written and faxed requests. The former resident was admitted on 01/11/24 and later discharged to the hospital after a fall with hip fracture, and subsequently died. On 10/30/25, the family’s attorney submitted an initial request for a certified copy of the resident’s medical record for a specified date range, providing the resident’s identifying information, a notarized affidavit of next of kin, a signed authorization for release of medical records, the death certificate, and contact information. The facility’s policy stated that residents or their representatives may obtain photocopies of records by providing at least 48 hours’ notice (excluding weekends and holidays). The facility’s medical records staff member reported that record requests are forwarded to the Administrator, who then sends them to corporate, and that records are not released until corporate approves what can be released. The attorney reported receiving only partial records on 12/11/25, including a consent to treat form for psychiatric therapy, the facility discharge form, a hospital history and physical, diagnosis and allergy audit reports, immunization audit report, order summary report, weight and vital summary, and the care plan report. On 12/15/25, the attorney notified the facility via fax and mail that the record was incomplete and specifically requested additional documents such as the MDS, all assessments, nursing notes, physician progress notes, therapy notes, MARs, TARs, caregiver notes, consultations, and ADL logs. Additional requests were sent on multiple later dates, with fax confirmations and documented phone calls and voicemails to the Administrator, but there was no response indicating that the missing portions were provided. The Administrator confirmed receiving all of the dated requests and stated that they were forwarded to corporate and that, to her knowledge, the complete record had been sent, but she did not provide a corporate contact number when asked. This sequence of events shows that the facility did not provide timely and complete access to the former resident’s medical record as required by its own policy and regulatory expectations.
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