Failure to Provide Complete Medical Records Upon Resident Request
Summary
The facility failed to ensure that a resident's request for access to and copies of her complete medical records was honored in a timely and comprehensive manner. The resident, who was cognitively impaired and required some assistance with activities of daily living, along with her elderly advocate, made multiple requests for her medical records, including medication and treatment administration records. Despite signing the required release form and following facility protocol, the resident and her advocate were repeatedly denied access to the full set of requested records. Staff interviews confirmed that the corporate compliance office directed them not to provide medication and treatment administration records, regardless of the resident's request or the completion of the release form. Facility policy stated that all information in the medical record could be released with written consent and that access should be provided within 24 hours, with hard copies available after 48 hours. However, the process involved sending the release form to the corporate compliance office, which then determined what records could be released. As a result, the resident did not receive all requested records, specifically the medication and treatment administration records, despite multiple attempts and clear communication of her needs. This deficiency was identified through medical record review, interviews with the resident, her advocate, staff, and review of facility policy.
Penalty
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Below are regulatory guidelines relevant to this citation:
A former resident who had been hospitalized after a hip fracture and later died had her medical records requested by her family’s attorney, who supplied all required authorizations and identifying documents. The facility initially sent only partial records and, despite repeated written, faxed, and telephone follow-up requests for specific missing items such as MDS, assessments, nursing notes, MD progress notes, therapy notes, MARs, TARs, and ADL logs, did not provide evidence that a complete record was released within the timeframe outlined in its own policy. The medical records staff stated that all requests are routed through the Administrator to corporate and are not released without corporate approval, and the Administrator acknowledged receiving multiple requests and forwarding them to corporate but could not provide a corporate contact, resulting in delayed and incomplete access to the former resident’s records.
The facility did not ensure reasonable access to medical records for a resident and family when they requested copies of PT/OT reports after discharge. The resident had multiple chronic conditions, severe cognitive impairment, and used mobility aids. Staff required the resident to appear in person to sign a release, would not accept a verbal request, and the daughter delayed the visit due to the resident’s limited mobility and weather. The daughter was reportedly told therapy records would cost $60–$80, leading the family not to obtain them. The facility’s fee schedule allowed high per-page and search fees, therapy records were controlled by a contracted provider with its own pricing, and facility staff could not provide clear cost information to the family, resulting in a lack of easy access to the requested records.
A resident with multiple chronic conditions requested copies of her medical records, but the facility failed to provide them after initially citing a broken copier. Although the records were eventually copied, they were not given to the resident, contrary to facility policy granting residents access to their records.
A resident's personal representative, through a law firm, made multiple requests for the resident's complete medical records, including a signed authorization and court order, but the facility did not provide access to the records until several months later. Staff interviews confirmed the delay was due to a former medical records employee not fulfilling the requests, resulting in noncompliance with timely record release requirements.
Two residents and their representatives were not provided timely access to their medical records after making valid requests, including one case involving an attorney and another involving a subpoena. Facility staff were unclear about procedures following a change in ownership and did not follow policy requiring records to be provided within two business days, resulting in significant delays.
A resident's family member made multiple requests for medical records, but the facility failed to respond or inform the family of the process, resulting in a delay. The staff responsible was unaware of the request due to absence, and the Administrator was not notified, contrary to facility policy requiring prompt handling of such requests.
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.
Failure to Ensure Reasonable Access and Fees for Resident Medical Records
Penalty
Summary
The facility failed to ensure ease of access for a resident and the resident’s family to obtain copies of the resident’s medical records, specifically therapy records. The resident, who had diagnoses including peripheral vascular disease, hypertensive heart disease without heart failure, encephalopathy, difficulty walking, dysphagia, atherosclerotic heart disease, kidney disease, alcohol abuse, and chronic peripheral disease, was severely impaired for daily decision making and used a wheelchair and front-wheeled walker for mobility. After discharge, the resident’s daughter requested physical and occupational therapy reports so home health could review what therapy had been provided. She was told the resident would need to come in person to sign a release form because the facility would not accept a verbal request, and the facility required a resident signature unless a power of attorney or other legal representative was in place. Due to the resident’s limited mobility and cold weather, the daughter did not bring him in to sign until a later date. The daughter reported being told by therapy staff that obtaining copies of the therapy records would cost approximately $60 to $80, and due to this reported cost, the family did not obtain the records. The facility’s fee schedule, based on the Ohio Revised Code and Consumer Price Index, allowed charges up to $3.88 per page for requests by a resident or resident representative, and for other requesters included an initial search fee of $23.94 plus up to $1.58 per page. The Administrator stated that therapy was provided by a contracted company using a different computer system and that this company set its own prices for records, which the Administrator did not know or verify for compliance, and that the facility used state fee requirements rather than federal. The Administrator also confirmed that the facility’s fee structure included additional fees for locating records and that verbal requests were not accepted. Medical Records staff indicated that requests required a signed release form, were routed through Quality Assurance and legal, and that the business office had a price sheet, but staff did not inform requesters of the cost. Corporate Business Office staff stated that charges were sometimes waived depending on page count and that the facility business office could not give residents or representatives a price, with therapy records handled separately by the third-party therapy agency.
Failure to Provide Resident Access to Medical Records
Penalty
Summary
A resident with multiple medical conditions, including multiple sclerosis, obstructive sleep apnea, obesity, hypertension, anemia, anxiety, PTSD, asthma, major depressive disorder, and COPD, requested a copy of her medical records from the facility. The resident, who was cognitively intact and dependent on staff for medication administration but independent in some activities of daily living, made her request to the Medical Records Manager (MRM). The MRM informed the resident that the copier was broken at the time of the request and stated that copies would be provided once the copier was repaired. Despite the copier being repaired, the MRM did not follow up with the resident or provide the requested records. The copied records remained in the office, and the resident did not receive them. Facility policy confirmed that residents have the right to access their medical records at any time. This failure to provide the requested records was confirmed through interviews, observation of the undelivered records, and review of facility policy.
Failure to Timely Provide Resident Medical Records
Penalty
Summary
The facility failed to provide timely access to medical records for a former resident whose personal representative, through a law firm, submitted a request for a complete copy of all records. The initial request, accompanied by a signed medical authorization and a court order, was made on 03/31/25, with a follow-up request on 05/12/25. Despite these requests, the records were not made available until 08/20/25, when a secure link was finally provided to the law firm. Review of the uploads confirmed that the resident's medical records were uploaded on 08/13/25, but access was not granted until a week later. Interviews with staff revealed that the delay was due to the former medical records employee's failure to fulfill the requests, which was later confirmed by the Licensed Nursing Home Administrator. The facility's policy required approval from the Corporate Clinical Director and written consent for record release, but these procedures did not result in timely fulfillment of the requests. The deficiency was identified during a review of medical record requests, emails, staff interviews, and facility policy, and affected one resident out of three reviewed for such requests.
Failure to Provide Timely Access to Resident Records
Penalty
Summary
The facility failed to provide timely access to resident records upon request, affecting two residents who had requested their medical records or had requests made on their behalf. In the first case, a resident with intact cognition had an attorney request the entire electronic nursing home chart for estate purposes. Despite multiple written requests and follow-up communications, the records were not provided for over a month. Facility staff, including the medical records staff and the administrator, were uncertain about procedures for records from before a recent change in facility ownership. Staff communications with the regional legal department revealed confusion and delays, with instructions to wait for a subpoena before releasing records, and no clear direction on handling records from the previous ownership. The attorney eventually threatened to subpoena the records due to the lack of response. In the second case, a resident with impaired cognition requested all records, and a subpoena was later issued for the documents. The medical records staff confirmed that no records had been provided since the change in ownership and was unaware of the request or the requirement to provide records in a timely manner, even for residents admitted under previous ownership. Facility policy required that records be provided within two business days of a written or oral request, but this policy was not followed. The deficiency was identified through record review, staff interviews, and policy review, confirming that the facility did not comply with its own procedures or regulatory requirements for timely access to resident records.
Failure to Timely Address Medical Record Request
Penalty
Summary
The facility failed to address a request for medical records in a timely manner for a resident with severe cognitive impairment and multiple diagnoses, including altered mental status, psychosis, encephalopathy, anxiety, restlessness and agitation, depression, sepsis, hypertension, and a history of cerebral infarction. The resident's family member initially requested the medical records via email, followed by a second email one week later, but did not receive a response from the facility regarding the process for obtaining the records. Staff interviews revealed that the Social Service Designee (SSD) was unaware of the request until after returning from vacation, and the Administrator had not been notified of the request at all. Facility policy required that requests for records be referred to the DON, Administrator, or another designated staff member, with records to be provided within two days after payment. The lack of response and failure to follow policy resulted in the deficiency.
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