Health inspection·October 29, 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 resident rights were honored for 1 of 3 sample residents (1) when the Medical Record Department (MRD) could not provide evidence that Resident 1's representative received copies of the medical record requested in a timely manner. As a result, there was a delay in reviewing Resident 1's medical record. Findings: Resident 1 was admitted to the facility on [DATE] with diagnoses which included hemiplegia, per the admission Record. On 10/2/24 at 2:20 P.M., an unannounced onsite visit at the facility was conducted for an complaint investigation related to a medical record request. On 10/2/24 at 3 P.M., an interview was conducted with the Medical Record Director (MRD). The MRD stated she did not have a log of the names of the residents or representatives who requested access to medical records. The MRD further stated their process was for the resident or representative to complete the request form. The MRD then asked the corporation via e-mail for approval to release the medical records, and once the request was approved, she prepared the documents. The MRD stated she was unsure when the resident or the representative should receive a hard copy of the medical record. The MRD stated Resident 1's representative wrote them a letter dated 6/25/24 requesting to get a copy of Resident 1's medical record. She completed the request form and e-mailed the corporate on 7/23/24. The MRD stated the corporation responded to her e-mail on 7/30/24. The MRD printed Resident 1's medical record, and the representative picked up the copies around 8/2/24. A follow-up interview and policy review were conducted with the MRD. The MRD stated the representative did not receive the medical record within two working days and should have. On 10/2/24 at 4:30 P.M., an interview was conducted with the Director of Nursing (DON). The DON stated that the facility's policy and procedure for requesting medical records should have been followed. Per the facility's policy and procedure, dated 10/1/15, titled Resident Access to PHI [Protected Health Information], .provide the resident and/or their personal representative with a copy of the medical record within two (2) working days after receiving the written request .Documentation A. The facility will document the following information on HP-08-Form C- Log of Requests for Access to PHI Page 1 of 2 555878 555878 10/29/2024 Granite Hills Healthcare & Wellness Centre, LLC 1340 E Madison Ave El Cajon, CA 92021

F 0573 .The date the Facility's response . Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 555878 Page 2 of 2