Can Nursing Homes Be Liable for Withholding a Resident’s Medical Records

When nursing homes withhold medical records, it can severely impact a resident’s care and potentially indicate neglect. Understanding you and your loved one rights can help you protect their well-being.

If a nursing home is concealing your loved one’s medical record, you may be able to seek legal action. Our experienced Santa Fe nursing home abuse lawyers are here to help you understand your legal rights during a free consultation. We do not charge any upfront costs or fees for a consultation or to move your case forward. Our firm only gets paid if you do.

Discover your legal options today: 505-677-7777

What Medical Records Nursing Homes Are Required to Keep?

Federal law requires medical records to be accurate, complete and readily accessible to those who can legally access them. Documentation provides vital evidence of care quality and can reveal patterns of neglect if problems arise.

Nursing homes must maintain detailed medical records for each resident. These records include:

• Admission and Discharge Documentation: This tracks a resident’s entry and exit from the facility.
• Medical Assessments, Diagnoses and Treatment Plans: Document the resident’s health status and care needs.
• Observations and Interventions: Healthcare providers must document observations and interventions through progress notes.
• Care Plans and Daily Care Records: Nursing staff maintain detailed care plans and daily care records.
• Behavioral and Physical Recovery Rehabilitation: The facility must also keep thorough documentation of behavioral health services, physical therapy and rehabilitation progress.
• Assessment of Nutrition Plans: Dietary teams contribute to residents’ medical records by documenting assessments and nutrition plans to ensure that residents do not face the risks of malnutrition and hydration.
• Emergency Care Records: This document any urgent medical situations and responses.
• Laboratory and Test Results: Lab and test results provide objective data about the resident’s health status.

How Long Must Nursing Homes Keep Medical Records?

In New Mexico, nursing homes are required to retain medical records for 10 years from the date of the patient’s last treatment.

Here are the specific requirements for nursing home medical record retention in New Mexico:

• Active Resident Records: Must be maintained throughout the resident’s stay.
• Discharged Resident Records: Must be retained for a minimum of five years after discharge
• Medicare/Medicaid Records: Healthcare providers are typically required to keep these records for six years to comply with federal regulations.

Who Can Access a Resident’s Medical Records?

Residents or their representatives must provide written consent for record release in most cases. However, nursing homes cannot use this requirement to unnecessarily delay or prevent access.

Several parties have legal rights to access nursing home medical records:

The Resident

Residents have the right to access their own medical records even if they have a cognitive condition. However, they may need assistance and support to do so. This allows them to stay informed about their health and treatment plans.

Typically, if a resident wants access to their medical records, they must submit a written request to the nursing home. In some cases, a resident may not be able to do so, therefore their legal representative can do so on their behalf.

Legal Guardians or Power of Attorney Holders

If a resident has an appointed legal guardian or someone with power of attorney, that person has the right to access the resident’s medical records. Note, that guardians and power of attorney holders must provide documentation proving they have authority to access resident’s medical records.

Authorized Family Members

Family members who have been authorized by the resident can access medical records. This is necessary for facilitating care or making medical decisions. The resident may need to provide written consent to grant access to family members.

Healthcare Providers Involved in Care

Doctors, nurses and other healthcare providers who are directly involved in the resident’s care have the right to access medical records to ensure proper treatment.

State and Federal Inspectors

Inspectors from state and federal agencies, such as New Mexico Department of Health or the Centers for Medicare & Medicaid Services (CMS), have the right to access medical records during inspections or investigations. Inspectors are granted access to ensure nursing home facilities are compliant with healthcare standards.

Legal Representatives in Case of Litigation

Attorneys representing a resident in legal matters have the right to access medical records that are relevant to the case. Legal representatives must typically provide a subpoena or other legal documentation to obtain access to the records.

What Happens if a Nursing Home Withholds Medical Records?

When nursing homes withhold records, it could indicate an attempt to hide negligent care. It may also show that a facility has poor procedures.

When nursing homes withhold medical records, they may face HIPAA Violations. HIPAA laws require nursing homes to give access to medical records within 30 days of a request. Failure to do so could lead to fines and penalties.

Other penalties may include:

• Federal and state fines
• Licensing penalties
• Civil litigation
• Criminal charges

Call PKSD for a Nursing Home Neglect Attorney

If your loved one’s medical records are not being released and you suspect nursing home neglect, contact PKSD immediately. Our experienced attorneys understand federal and state regulations governing medical record access. We can help obtain withheld records and review documentation for signs of neglect.

Do not let nursing homes hide evidence of neglect. Our team works on a contingency fee basis, meaning you pay nothing unless we win your case. We will investigate thoroughly and fight for the justice you and your loved one deserves.

Schedule your free consultation today: 505-677-7777