Health inspection·September 13, 2024

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 medical records requested by one of four sampled residents (Resident 1), were released within 24 hours as indicated in the facility ' s policy and procedure (P&P) titled Residents Rights, Release of Information. This deficient practice resulted in the violation of a residents ' rights and had the potential to affect Resident 1 ' s quality of life. Findings: During a review of Resident 1 ' s admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE], and re-admitted on [DATE] with diagnoses including dementia (loss of cognitive function), cardia pacemaker (electrical pulses to produce heartbeat), and hypertension (HTN-high blood pressure). During a review of Resident 1 ' s History and Physical (H&P) dated 8/1/2024, the H&P indicated Resident 1 has fluctuating capacity to understand and make medical decisions. During a review of Resident 1 ' s Minimum Data Set ([MDS] a standardized care assessment and care screening tool), dated 8/5/2024, the MDS indicated Resident 1 had the ability to make self-understood and the ability to understand others. The MDS indicated Resident 1 was dependent with activities of daily living (ADLs) such as dressing, toilet use, personal hygiene, transfer (moving between surfaces to and from bed, chair, and wheelchair) and bed mobility (how resident moves from lying to turning side to side.) During a review of legal services office (TLS) fax transmission result dated 8/12/2024, indicated fax requesting Resident 1 ' s medical records (MR) was successfully sent to the facility on 8/12/2024 at 4:39 p.m. During a review of TLS email dated 8/26/2024 at 12:03 p.m., the email indicated TLS was following up on Resident 1 ' s MR request. During a review of TLS email dated 8/29/2024 at 11:49 a.m., the email indicated TLS was following up on Resident 1 ' s MR request. During a review of TLS email dated 9/5/2024 at 4:14 p.m., the email indicated TLS was following up on Resident 1 ' s MR request. Page 1 of 2 055519 055519 09/13/2024 Downey Post Acute 13007 S. Paramount Blvd. Downey, CA 90242

F 0573 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During a concurrent interview and record review on 9/13/2024 at 11:20 a.m. with Medical Records Director (MRD), the MRD stated if a resident ' s family or representative requested MR, they need to sign a release authorization letter. The MRD state when documents are requested by a law firm, the request is sent via e-mail to the facility law firm and wait for their advice. The MRD stated, MR requested by family usually takes 24 hours to complete, but for law firms, MR are released after a request based on the subpoena (court) order. The MRD reviewed August 2024 release information log and indicated TLS requested MR for Resident 1 on 8/8/2024. During a concurrent interview and record review on 9/13/2024 at 12:20 p.m. with MRD, the MRD stated she (MRD) she received email from TLS on 8/20/2024 that included signed authorization release letter. The MRD stated on 8/23/2024, the MR request was emailed to the facility ' s legal team. The MRD stated on 8/27/2024, the facility ' s legal team approved the release of Resident 1 ' s MR to TLS. The MRD could not explain why it took 9 days to send to TLS, Resident 1 ' s requested MR after the facility ' s legal team approved the request. The MRD stated the facility should provide the MR when requested. The MRD stated it was Resident 1 ' s rights to receive the MR requested in a timely manner. The MRD stated it was our responsibility to provide all MR in a timely manner. During an interview on 9/13/2024 at 2:00 p.m. with Director of Nursing (DON), the DON stated it was important to follow up and make sure the requested MR were released to TLS as soon as possible after the facility consultant approved the release. The DON stated it was not acceptable for TLS and Resident 1 to wait for about a month for the MR to be released. During a review of the facility ' s P&P titled Residents Rights, Release of Information, dated 9/2020, the P&P indicated residents may initiate a request to release information contained in his/her records and chart to anyone he/she wishes after a written, signed, and dated request received from the resident or representative (sponsor), by providing the facility 48 hours advance notice. The P&P indicated residents may have access to his or her records within 24 hours (excluding weekends or holidays) of the resident ' s written or oral request. 055519 Page 2 of 2