Failure to Release Resident Records to Authorized Representative
Summary
The facility failed to treat the decisions of a resident representative as the decisions of the resident to the extent delegated by the resident for one resident whose records were reviewed. The resident had been admitted with diagnoses including orthostatic hypotension, a personal history of malignant neoplasm of the breast, and acquired absence of the right breast and nipple. Her MDS assessment showed a BIMS score of 5 out of 15, reflecting severe cognitive impairment, and participation in assessment and goal setting included the resident and a family member. Her admission paperwork identified a family member as the representative and emergency contact, and the resident preferred that family member to sign the disclosure authorization. After the resident was discharged, the family member requested copies of records related to an incident, including incident reports, nursing and clinical notes, staff names and titles, facility policies, internal documentation, and CT scan results. The family member stated he also requested the resident’s medical records by letter and by telephone. The facility responded that it could provide copies of the resident’s medical records only after receiving a completed medical records authorization from the legally authorized representative, and staff told the family member that a POA would be needed before records could be released. The DON stated the family member had requested the resident’s entire medical record but would not provide a POA, and corporate advised that the records could only be released if a POA was provided. The medical records staff stated she could release records with an authorization for release of medical records and that legal would verify POA status, but she also followed facility protocol. The administrator stated he had been advised by the legal team that records could only be released to the family member upon provision of a POA, and the facility policy stated that a resident may authorize release of personal and clinical records as provided by law and that if records are requested by family, a medical records release form must be completed.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Delay in Providing Requested Medical Records: A resident’s representative requested copies of the resident’s medical records, but the invoice was not sent promptly and the records were not released within the expected timeframe. Staff stated the request was received, payment was required, and the records were eventually sent after payment was received, but there was no documentation showing when payment arrived and staff were unclear on the time-sensitive release process.
Delayed Access to Medical Records: The facility failed to provide timely copies of medical records for two residents after requests were made. One resident had heart failure, anxiety, edema, depression, and HTN, and another had epilepsy, anxiety, and depression; both had requests for full chart copies, but the records were not available within two working days. The facility policy did not give a timeframe for releasing records.
Failure to provide requested medical records timely. A resident with dementia, anxiety, and a pacemaker, living on the secured memory care unit with a POA, was involved in a resident-to-resident altercation. The POA requested copies of the resident’s records related to the incident, but the facility did not mail the records within the required 2 working days after the written request was received.
A resident’s RP requested copies of the resident’s medical records, but the facility did not release them in a timely manner. The MRD confirmed the request was received and said the facility waited for additional records before sending anything, with no contact made to the RP after the request. The DON confirmed the facility’s policy required copies to be provided within two business days of a completed authorization, but the records were not provided until 41 days after the request was received.
Failure to Provide Requested Medical Records Within Required Timeframe: A resident with encephalopathy and a communication deficit had a RP request copies of medical, billing, and radiology records sent to the RP’s law firm, but the facility did not send them within the 48-hour timeframe in its PHI policy. The MRD stated she believed her assistant had sent the records, but the assistant had not, and the DON stated the delay violated the resident’s rights.
Delayed Access to Resident Medical Records: The facility failed to provide a resident’s family timely access to medical records after a request was made. The resident had dementia and other diagnoses, and the BIMS score showed impaired cognition. Email records showed approval from the regional office, then a delay before pricing was sent and another delay before the records were emailed. The RA verified there was no record of the initial request and no additional documentation of phone or in-person communication.
Delay in Providing Requested Medical Records
Penalty
Summary
The facility failed to provide a resident representative with a copy of Resident 1’s medical records within the required timeframe after a written request was submitted. Resident 1 was admitted to the facility on an unspecified date and was discharged on April 5, 2026. The resident’s representative submitted the request for the medical records on May 6, 2026. The facility prepared an invoice on May 7, 2026, but it was not emailed until May 12, 2026, and the requested records were not transmitted until May 26, 2026. During interviews, the Medical Records Assistant stated she received the request on May 6, 2026, informed the representative that payment was required, and prepared the invoice the next day, but did not email it until several days later because she had many responsibilities. She stated she was not aware that requests for medical records were time-sensitive and had not received direction regarding the release process. The Administrator stated records are generally sent within two days once payment is received, but he did not know when payment was received because there was no documentation showing when it arrived. The Business Manager stated she recalled opening the payment envelope after returning from the holiday weekend, but could not determine when the payment had actually been delivered to the facility.
Delayed Access to Medical Records
Penalty
Summary
The facility failed to ensure that residents received timely copies of their medical records after requests were made. For Resident #75, who had diagnoses including heart failure, anxiety, edema, depression, and hypertension, the record showed an admission date of 10/10/25 and discharge to the community on 04/02/26. The resident’s MDS assessments reflected a change from intact cognition on admission to severely impaired cognition on the quarterly assessment dated 01/30/26, and the LSW stated the resident refused to participate in that assessment. An Authorization for Use or Disclosure of Protected Health Information form signed by Resident #75 on 02/05/26 requested a copy of the entire medical record for personal use, and an email from corporate on 02/11/26 stated the records were attached and should be provided to the resident. A second request for Resident #75’s records was documented on a form signed on 05/02/26, with facility email correspondence showing the request was emailed on 04/02/26; the facility later attempted to contact the resident on 04/06/26 and left a voicemail on 04/07/26 stating the records were available for pickup. For Resident #77, who had diagnoses including epilepsy, anxiety, and depression and had intact cognition on the 5-day MDS assessment completed 03/05/26, the resident’s POA signed an authorization on 03/26/26 requesting a copy of the entire medical record for treatment, payment, other healthcare operations, and personal use. The facility’s records showed Resident #77’s records were available for pickup on 04/03/26. The Administrator confirmed that copies of the medical records for both residents were not available within two working days of the requests, and the facility policy on Release of Information did not include guidance on the time required to provide copies.
Failure to Provide Requested Medical Records Timely
Penalty
Summary
The facility failed to provide copies of a resident’s medical record within two working days after advanced notice was given. Resident #40, who had an admission date of 07/31/24, diagnoses including dementia with other behavioral disturbance, anxiety disorder, and presence of a cardiac pacemaker, and who lived on the secured memory care unit with a designated POA, was the resident involved in the request. The Quarterly MDS dated 01/30/26 showed severely impaired cognition, independence with ambulation, and no behaviors. The medical record showed that Resident #40 was involved in a resident-to-resident altercation on 02/26/26 at approximately 12:12 P.M. A written request for medical records related to that incident was sent by the POA on 03/17/26, and the correspondence stated the family had previously made a written request and that more than two weeks had passed. The facility’s certified mail receipt for the records request was postmarked on 03/20/26, three working days after the written request. The Administrator stated that 03/17/26 was the first written request received and verified the records were not sent within two working days. The facility policy stated that upon receipt of a request for medical record copies, the facility should notify the requesting party in writing of the cost and that records were available two days after receipt of payment.
Delay in Release of Resident Medical Records
Penalty
Summary
The facility failed to ensure that the medical records of one sampled resident were released in a timely manner to the resident’s Responsible Party after a valid request was received. Resident 1 was admitted with diagnoses including dementia, anemia, bipolar disorder, and schizophrenia. The resident’s H&P dated 5/30/2011 indicated the resident had the capacity to understand and make decisions. RP 1 submitted a request for a copy of Resident 1’s medical records on 5/27/2026 during the resident’s stay at the facility. During interview and record review, the Medical Records Director confirmed the request was received on 5/27/2026, but the facility did not send the records at that time. The MRD stated the facility had received records from 2011 through 2017 but was waiting to receive records from 2017 through 2021 before sending anything to RP 1, and no contact was made with RP 1 after the request was received. The DON reviewed the facility’s policy stating copies of records are to be provided within two working business days of receipt of a completed authorization, and confirmed the facility should have communicated with RP 1 and provided the requested records in a timely manner. The records were ultimately provided to RP 1 on 7/7/2026, 41 days after the request was received.
Failure to Provide Requested Medical Records Within Required Timeframe
Penalty
Summary
The facility failed to provide requested medical records within 48 hours for one sampled resident when the resident’s responsible party submitted a written request for copies of the resident’s medical records, billing records, itemized billing statements, charges, payments, adjustments, and radiology imaging to be sent to the responsible party’s law firm. The request was faxed on 6/2/2026 at 8:42 AM, but the records were not sent until 6/5/2026 at 11:52 AM, 75 hours later. The facility’s policy titled Protected Health Information stated that a resident may access records within 24 hours of a written or oral request and may obtain photocopies of records by providing 48 hours’ advance notice. Resident 1 had diagnoses including encephalopathy and a communication deficit. The Minimum Data Set dated 5/27/2026 indicated the resident never or rarely made decisions regarding tasks of daily life and was rarely or never understood. During interview, the MRD stated the facility had 48 hours to send medical records when residents or their RP requested them, and acknowledged that Resident 1’s records should have been sent within that timeframe but were not. The MRD stated she failed to follow up on the request because she believed her assistant had sent the records, but the assistant had not. The DON stated it was a resident’s and RP’s right to obtain copies of medical records and that failing to provide them within 48 hours violated the resident’s rights.
Delayed Access to Resident Medical Records
Penalty
Summary
The facility failed to ensure that a resident or the resident’s legal representative had timely access to medical records after a request was made. Resident #49 was admitted on 04/06/26 and discharged on 05/05/26, and the medical record showed diagnoses of muscle weakness, dementia, anxiety, depression, edema, heart disease, and Alzheimer’s disease. The MDS assessment documented a BIMS score of 05, indicating impaired cognition. Email correspondence showed the request for medical records was approved by the regional office on 05/12/26. On 05/18/26, facility administration emailed the resident’s family pricing of $206.32 for the records and provided the regulations related to medical record requests. The records were then emailed to the family on 05/26/26. During interviews, the Regional Administrator verified the facility had no record of when the family initially requested the records and no additional evidence of communication by phone or in person. She also verified the facility policy required records to be provided within 24 hours, or paper copies within two business days, and that it took about a week to provide pricing information and about two weeks after approval to send the documentation.
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