Failure to Provide Timely Access to Resident Medical Records
Penalty
Summary
The facility failed to provide timely access to medical records and to maintain a medical records policy consistent with regulatory requirements. The facility’s undated policy, “Release of Resident Medical Records,” stated that records for active residents must be provided within two working days and records for non-active residents within 15 days. Resident 5, who had diagnoses including aftercare for right hip dislocation, dementia, and malnutrition, had a comprehensive assessment dated 11/03/2025 indicating a need for partial to dependent assistance with ADLs and moderately impaired cognition. The resident’s representative reported requesting the resident’s records, but the facility did not provide them as requested. Record review showed the representative emailed a request for the resident’s records on 02/04/2026, and an Authorization for Release of Information form was completed and provided to the facility on an unspecified date. The facility did not provide the records until 02/21/2026, nine days after receiving the authorization form, despite the representative having verbally requested the records prior to 01/29/2026. During interviews, the Medical Records Director stated that for current residents the facility had two days to provide records and for former residents 30 days, and that the process began when the release form was returned. The Administrator stated they were unsure of the regulations for record requests. These practices were inconsistent with the facility’s own policy and with applicable regulations, resulting in a failure to provide records within two working days for this resident.
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