Incomplete Release of Resident Medical Record to Family
Summary
The deficiency involves the facility’s failure to provide a complete copy of a resident’s medical record upon request by the resident’s next of kin. Facility policy on release of information, last reviewed on 1/9/26, stated that all information in a resident’s medical record is confidential and may only be released with written consent from the resident or legal representative. Closed Resident Record CR1 had multiple serious diagnoses, including pulmonary embolism, B-cell lymphoma, diabetes, hypertension, kidney disease, and cancer. On 1/9/26, a nurse practitioner documented that the resident exhibited signs consistent with a stroke, including a flaccid left upper extremity and slow speech, and ordered transfer to the emergency department for a higher level of care. A nurse’s note the same day documented the resident’s transfer to the hospital via stretcher, with an acute care transfer/change of condition form sent and the family notified. On 1/14/26, the facility received a signed request from the family for the resident’s medical record. Facility documentation showed that on 2/28/26 the family received a mailed four‑pound shipment of documents. However, by 3/5/26, the family reported concern that not all of the medical record had been released. In internal communications, administration indicated that Medical Records Personnel E1 believed the entire record had been sent. During an interview, E1 stated she had not received any additional records requests, believed she had given the family everything she had, and thought the nurse notes were included with the other records, but there was no evidence that the nurse notes were actually sent. Surveyors informed the Nursing Home Administrator and DON that the facility failed to provide a complete copy of the closed resident’s record upon the family’s initial request, in violation of 28 Pa Code 201.14(a) and 201.18(b)(2).
Penalty
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The facility failed to charge a reasonable fee for electronic medical records requested by a resident’s legal representative. A resident with respiratory failure, anemia, and metastatic lung cancer had a son with POA who requested records electronically and received the first set via email. After a second electronic request, the facility issued two invoices totaling over several hundred dollars based on a per-page fee schedule and refused to send the second set of records until both invoices were paid, despite Ohio law capping charges for digital or electronically transmitted records at a fixed amount for authorized requestors.
A resident with impaired cognition and a low BIMS score had a family member designated as POA for health care and related decisions. The POA became concerned about the resident’s care and requested the resident’s medical records but did not receive them. Nursing notes documented the POA’s expressed frustration about still waiting for the records. The Medical Records staff required the POA to complete authorization paperwork twice, stated the first set was completed incorrectly, and reported that corrected paperwork was not returned until after the resident’s death, at which point additional documentation was required. Staff acknowledged that the POA was authorized to act on the resident’s behalf and that, unlike a resident’s own oral request, the POA’s request was not honored without extra paperwork, resulting in the POA never obtaining the records.
A resident's family member emailed verified facility addresses for the ADON and social worker, and cc'd the LTC Ombudsman, requesting the resident's medical records and any required forms, but the request was not processed according to facility policy. The ADON acknowledged the emails were sent but did not recall seeing the request, while the social worker, who started after the first email, did not review earlier emails and denied knowledge of any request, stating such matters go through the Administrator. The Administrator reported being unaware of the family's request, despite confirming that an email requesting records had been sent to management addresses, and facility policy required all record requests to be referred to the Administrator for review, verification of access rights, and completion.
A resident with Parkinson’s disease, Lewy body dementia, chronic kidney disease, severe cognitive impairment, and functional limitations had a legal representative submit a written authorization requesting copies of the complete medical record. The facility lacked a specific policy directing staff to furnish records upon resident or representative request. The Administrator responded by quoting a copy fee and requiring payment before release, and the records were not mailed until several weeks later, well beyond the required 2 working days. The Finance Officer reported that the former Administrator independently managed this request, did not send the records timely, and that staff were unaware of the 2‑day requirement, believing they had a 30‑day timeframe.
A resident with CKD, major depressive disorder, and dementia, who was cognitively impaired and under a court-appointed plenary guardian, did not have their rights to timely access to personal, medical, and financial records honored. The guardian submitted a written authorization requesting medical and billing records over an extended period in electronic format, but the facility’s Medical Records Director, Social Services Director, and Business Office Manager did not coordinate to ensure the request was fulfilled within the required timeframe. Key staff reported being unaware of the request, cited the absence of the Business Office Manager and prior ownership of some records, and the guardian reported making multiple attempts, including an in-person formal request and follow-up calls, without receiving the requested records, contrary to facility policy and resident rights.
A resident with cerebral ischemia, type 2 DM, and moderately impaired cognition had a designated responsible party who requested the resident’s medical records through a legal services entity. The facility’s policy required resident access to records within 24 hours of request and photocopies within 48 hours, and staff reported an internal expectation to send records within seven working days. The MRD and DON stated that the chart was difficult to locate because it was stored in boxes, and the MRD had physical limitations, resulting in the records being sent after the required timeframe and violating the resident’s and responsible party’s right to timely access to medical records.
Unreasonable Fees Charged for Electronic Medical Record Requests
Penalty
Summary
The deficiency involves the facility charging an unreasonable fee for a resident representative’s request for medical records, in violation of Ohio Revised Code (ORC) 3701.742. The resident involved had acute and chronic respiratory failure with hypoxia, anemia, and metastatic lung cancer, with mild cognitive impairment and a need for moderate assistance with all ADLs. His son, who held financial and medical POA and was involved in his care and discharge planning, requested medical records electronically using the facility’s form. The first request was submitted and the records were sent electronically within a few days. The son later requested additional records electronically, again specifying he only wanted electronic copies. Following these requests, the facility generated two invoices for the son, one for the first set of records already provided and one for the second set requested, totaling over $600–$800 based on the facility’s fee schedule of per-page charges. The Regional Quality Assurance Manager and Corporate Medical Records staff confirmed that the second set of records would not be sent until the invoices were paid, despite the son only requesting electronic records. The facility’s policy referenced charging for photocopies in accordance with ORC 3701.742, but the applicable ORC provision limited the total cost for access to or electronic transmission of digital records, and all related services, to no more than fifty dollars when requested electronically by an authorized person. The facility’s invoicing and withholding of the second set of records until payment constituted the failure to charge a reasonable price for electronic medical records as required by state law.
Failure to Provide Resident’s Legal Representative Access to Medical Records
Penalty
Summary
The deficiency involves the facility’s failure to provide a resident’s legal representative with access to the resident’s medical records upon request. The resident had impaired cognitive function, an impaired thought process, and a Brief Interview for Mental Status (BIMS) score of 5, and had designated a family member as Power of Attorney (POA) with authority over long-term placement, health care, mental health including medications, and hospitalizations. According to the state agency complaint intake, the POA was concerned about the care the resident was receiving and requested the resident’s medical records before the resident passed away, but the facility never provided them. Nursing progress notes documented that the POA approached the Assistant Director of Nursing and staff, stating they were still waiting on medical records and needed to sign whatever was required to obtain them, and expressed that the delay was unacceptable. Interviews and record review showed that the Medical Records (MR) staff required the POA to complete paperwork to obtain the resident’s medical records, even though MR acknowledged that the POA was legally authorized to act on the resident’s behalf and that the resident did not have the capacity to request records independently. MR reported giving the POA the required forms twice, stating the first set was filled out incorrectly and that the POA needed to complete them again. MR further stated that the POA did not return the corrected paperwork until after the resident’s death, at which point the facility required additional paperwork to release records following a resident’s passing. MR also stated that if a resident personally requested their own medical records, an oral request would be sufficient and no paperwork would be required. Despite the POA’s requests and authority, the POA never received the resident’s medical records. The facility’s policy on determining validity of authorization for release of protected health information required the Medical Records Director to determine whether an authorization was needed for disclosure, but the records were not provided to the POA prior to the resident’s death.
Failure to Process Family Request for Resident Medical Records
Penalty
Summary
The facility failed to honor a resident medical records request in accordance with its own policy, affecting Resident #41. Record review showed that the resident's daughter sent emails on 03/15/26 and 04/25/26 to verified facility email addresses for the Assistant Director of Nursing (ADON) #563 and Social Worker #574, and carbon copied the Long-Term Care Ombudsman, requesting the resident's medical records and asking to be sent any required forms needed to complete the request. During an interview on 04/27/26 at 1:47 P.M., ADON #563 confirmed that these emails were sent but stated she did not recall seeing the records request. In a separate interview at the same time, Social Worker #574 reported she began employment on 03/16/26, one day after the first email was sent, and although she used the same social worker email address to which the request was sent, she did not review emails that predated her start date and denied knowledge of any records request, stating such requests would go through the Administrator. In an interview on 04/27/26 at 4:35 P.M., the Administrator stated he was not aware that Resident #41's family had made a records request, but confirmed that an email dated 03/15/26 requesting records had been sent to facility management addresses. Review of the facility's medical records release policy dated 06/01/24 showed that all resident record requests must be referred to the Administrator, who is responsible for ensuring each request is reviewed, the requesting party's access rights are verified, further information is requested if needed, and the relevant office is notified to complete the request. This process was not followed for Resident #41's records request.
Failure to Provide Timely Access to Resident Medical Records Upon Request
Penalty
Summary
The deficiency involves the facility’s failure to provide a resident’s legal representative with copies of the resident’s medical records within 2 working days of a written request, as required. The resident, who had Parkinson’s disease, Lewy body dementia, chronic kidney disease, severe cognitive impairment, required supervision for eating, moderate assistance for bathing, walked 10 feet with supervision, and was frequently incontinent of bladder and bowel, was admitted on an unspecified date. On 3/10/25, the resident’s representative completed and signed an Authorization for Release of Health Information form requesting the resident’s records from 2/14/25 to the present. The facility did not have a written policy or procedure directing staff to furnish records upon request from residents or their representatives, although a general Resident Medical Record policy dated 5/2025 stated that records would be maintained in accordance with federal and state regulations. Following the request, the Administrator sent a letter dated 4/11/25 to the resident’s representative stating that the cost of the copies would be $315.00, that payment was required before release, and that the check should be payable to the facility. The records were not mailed until 4/22/25, after the facility received payment, resulting in a delay far beyond the required 2 working days. During an interview, the Finance Officer stated they were responsible for reviewing record requests and obtaining fees before releasing records, and that in this case the former Administrator handled the request, did not date the records, and did not send them timely. The Finance Officer also stated they were not aware of the 2-day deadline and believed there was a 30-day window for providing records.
Failure to Provide Timely Access to Resident Medical and Financial Records
Penalty
Summary
The facility failed to provide a resident’s court-appointed plenary guardian with timely access to the resident’s personal and medical records within 24 hours of a written request, excluding weekends and holidays. The resident, who had chronic kidney disease, major depressive disorder, and dementia, was cognitively impaired with a BIMS score of 6/15 and had become a ward of the state with a guardian appointed by the county court. The guardian completed an Authorization for Use and Disclosure of Protected Health Information form requesting medical and billing records from the date of admission to the present, in electronic format. The Medical Records Director stated that the process for receiving records typically took two to three days and that corporate legal determined release of records. He recalled the guardian requesting medical and financial records and said she was given all the information she needed at the time, but also stated that financial records could not be provided because the Business Office Manager was not on the premises and that the guardian refused physical copies at that time. Despite the written authorization, the Social Services Director and Business Office Manager reported they were unaware of any request from the guardian and stated they had never met her nor received emails or calls requesting records. The Business Office Manager indicated that some earlier financial records were likely with the previous company that had operated the facility. The guardian reported she had requested medical and financial records, had been told she needed to make a written request, and later came to the facility to make a formal request but still had not received any records, despite multiple follow-up calls and being told by the Medical Records Director that the facility was still working on her request. The Nursing Home Administrator and Director of Nursing acknowledged that residents have a right to access their medical records at any time or as soon as possible, and the NHA stated that waiting almost a month for records was not acceptable, even considering that some records related to previous ownership. The facility’s policy stated that residents are to be allowed access to personal and medical records in a manner that acknowledges and respects resident rights, which was not followed in this case.
Failure to Provide Timely Access to Resident Medical Records
Penalty
Summary
The facility failed to follow its policy and procedure titled "Release of Information" for one sampled resident, resulting in the resident’s responsible party not receiving timely access to the resident’s medical records. The resident had been re-admitted with diagnoses including cerebral ischemia and type 2 DM, had moderately impaired cognition per the MDS, and was later discharged and subsequently expired. The admission record identified the resident’s daughter as the responsible party. A written request for release of the resident’s medical records was submitted by a legal services entity and was documented as received by the facility. The facility’s policy stated that a resident may have access to records within 24 hours of a written or oral request and may obtain photocopies with at least 48 hours’ advance notice, excluding weekends and holidays. The Medical Records Director acknowledged that the request from the legal services entity was received and that the facility’s policy required records to be sent within seven working days, but stated that the records were not sent within that timeframe. The Medical Records Director reported difficulty retrieving the resident’s records because they were stored in boxes in the back of the facility and the director had physical limitations. The Director of Nursing confirmed that the facility could not easily locate the resident’s chart and that the records were released only after the chart was found. Both the Medical Records Director and the Director of Nursing stated that it was the right of the resident or responsible party to request and receive the resident’s medical records in a timely manner, and that the records could be needed for legal purposes and, if the resident were alive, for continuity of care.
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