Health inspection·January 28, 2025

F 0573 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Let each resident or the resident's legal representative access or purchase copies of all the resident's records. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a resident was able to exercise the right to access personal and medical records for one of three residents (Resident 1), when medical records for Resident 1 were requested by a law firm for a legal matter but were not delivered within two working days of the request as per the facility's policy. This failure resulted in a violation of Resident 1's right to have access to medical records as requested by a law firm. Findings: During a review of Resident 1 Face Sheet (contain resident demographic), the Face Sheet indicated, Resident 1 was admitted on [DATE], with diagnosis that included multiple sclerosis (a chronic disease that damages the central nervous system, including the brain, spinal cord, and optic nerves) and was discharged on August 10, 2023. During a review of Resident 1 ' s Minimum Data Set (facility assessment tool), dated May 17, 2023, under Section C, it indicated her Brief Interview for Mental Status (BIMS) score was 15. (A BIMS score of 13 to 15 suggests the patient is cognitively intact.) During an interview on January 28, 2025, at 12:52 PM with the Director of Health Information (DHI), the DHI stated that she had received a request for medical records via fax, which was time stamped January 16, 2025, at 1:56 PM. The fax was sent to the Business office fax number, but she did not receive it until January 24, 2025. She elaborated that the requested documents had not been dispatched as she was still awaiting approval from the facility's legal team to release them, and she had not yet reached out to the law office representing Resident 1. During a review of a facsimile request from Resident 1 Legal Representative dated January 16, 2025, indicated a request for records to be provided within two working days following the receipt of that correspondence. During a concurrent record review and interview with the DHI, the Director of Nursing (DON), and the administrator (Admin). The facility Policy and Procedure (P&P) titled, Release of information statement , November 2009, was reviewed. The P&P indicated, .9. A resident may have access to his or her records within 48 hours (excluding weekends or holidays) of the resident's written or oral request. 10. A resident may obtain photocopies of his or her records by providing the facility with at least a forty-eight (48) hour (excluding weekends and holidays) advance notice of such request. A fee may Page 1 of 2 055213 055213 01/28/2025 Rialto Post Acute Center 1471 S Riverside Ave Rialto, CA 92376

F 0573 Level of Harm - Minimal harm or potential for actual harm be charged for copying services. The DHI acknowledged a delay in the distribution of the documents, noting a shortcoming as the documents were not dispatched within the specified time frame, and both the DON and the Admin concurrently agreed. Residents Affected - Few 055213 Page 2 of 2