HospitalInspections.org

Based on document review and interview, it was determined in 1 of 1 (Pt #1) clinical record reviewed in which a request for medical records was made, the hospital failed to ensure patients obtained medical records as requested.
Findings include:

1. The clinical record of Pt #1 was reviewed 4/16/14. P #1 an 88 year old female was admitted 11/13/13 to the Center of Senior Behavioral Health Unit with diagnoses of Delirium and Confusion. P #1 was discharged to a nursing home 12/16/14. An "Authorization for Use or Disclosure of Information" form signed by Pt #1 on 1/1/14 requested the complete medical file including all medications given be disclosed for the continuation of care.

2. On 4/16/14 at approximately 1:40 PM an interview was conducted with the Director of Behavioral Health (E2). E2 stated Pt #1's medication list was requested during the hospitalization but the list was not available until after Pt #1 was discharged due to computer problems. E2 stated after receiving the "Authorization for Use or Disclosure of Information" form the Medication Administration Record only was mailed as requested although the date could not be confirmed. E2 stated the completed authorization form was sent to the Medical Records Department for filing.

3. On 4/17/14 at approximately 11:00 AM, an interview with the Director of Medical Records (E4) was conducted. E4 stated since the "Authorization for Use or Disclosure of Information" form was received from E2, the Medical Records Department filed the form as completed. E4 stated, "medical records were not sent on this patient. I didn't know medical records were requested since it wasn't entered on the request log."

4. The Senior Behavioral Health Unit policy "Release of Information" (reviewed 9/11/13) was reviewed 4/17/14 at 11:00 AM. The policy stated "8. Medical records will be responsible for Release of Information after patient is discharged."