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Based on review of medical records and hospital policies, and interview, it was determined the hospital failed to establish policies and procedures that ensured patients' representatives received patients' rights information. This impacted 1 of 1 patient (#1) who was incapacitated and had a legal guardian who was not present during the admission process. This resulted in a representative not having the required information necessary to exercise rights on behalf of the patient. Findings include:

Patient #1 was an 82 year old female admitted to the hospital on 11/16/11 for treatment of a small bowel obstruction (which required surgery to correct) and sepsis (an infection in the blood stream). Prior to hospitalization, she resided in a SNF and was discharged back to the SNF on 11/30/11.

Patient #1's medical record indicated she was admitted to the hospital after an evaluation in the ED. Her medical record contained documentation transferred with her from the SNF, including legal documents of appointment of guardianship. The ED physician documented attempting to contact the guardian to discuss Patient #1's care and treatment, but noted the guardian was not available when Patient #1 was admitted.

Patient #1's medical record contained a "Conditions of Admission" document which was signed by a registrar and a second witness. The registrar wrote "Pt [patient] unable to sign at all."

On 4/18/12 at 11:00 AM, a Registrar who worked with admissions from the ED was interviewed. She explained her role in the admission process, obtaining signatures for the "Condition of Admission" document, and dispersing patient rights information when the patient was not able to participate in this process. She stated if the patient's representative was available they would be given the patient rights information and asked to sign the "Condition of Admission" form.

She stated if the patient was not able to participate in the admission process due to their mental status, and there was no representative present at the time, she relied on the ED nurse caring for the patient to know if the guardian or DPOA would be in the see the patient at some point during the stay. If someone was going to be available at a later date, the admission paperwork would be placed in a "need more info [information]" basket to be completed later. She explained that whichever registrar had time would follow up on obtaining the appropriate signature and providing the patient rights information. If the patient was incapacitated and did not have a representative that the facility was aware of, she documented on the "Condition of Admission" form the patient was unable to sign, and had an RN cosign.

She stated if the admission paperwork was not given to the patient or representative, and the registration office was not planning to follow up on the documentation, the information, including patient rights, was transferred with the patient from the ED to their assigned room. She stated she was not sure if this information was passed on to a representative/guardian, or even to the patient if their mental status cleared enough to enable them to understand their patient rights. She confirmed that the only time a registrar contacted a legal guardian, was if the patient was a minor.

A Registrar who worked with outpatient services and patients who were directly admitted to the hospital was interviewed on 4/18/11 at 11:30 AM. She stated she always reviewed the "Condition of Admission" form with the patient, explained the patient rights and responsibilities, and offered them the patient handbook with this information. She stated if a patient required a representative to sign on their behalf and receive information, and the representative was not present upon admit, she would ask the patient if the representative would be coming in at a later time and then place the documentation in a "need sigs [signature]" basket in the admissions area. She stated if a representative was not coming in at all, the paperwork would be signed by two registrars and the information would be sent with the patient. She was not certain that nursing staff on the floor passed on patient rights information to either the patient and/or the appropriate representative if the information had not already been disseminated.

RN B was interviewed on 4/18/12 at 3:15 PM. She stated if a patient was admitted to her care and she was aware the patient had a guardian or representative, she passed this information on to the physician in order for the physician to discuss care and treatment plans with the appropriate individual. She stated she did not contact patients' guardians or representatives. She explained if admission documentation needed to be signed by a patient representative, this was completed by the registrars. She confirmed she did not disperse patient rights information to guardians/representatives if they were not present during the admission process with the registrar, and that this was typically handled by the registrar or a case manager.

A Service Line Coordinator, RN Case Manager, was interviewed on 4/19/12 at 9:00 AM. She stated she did not have a role in ensuring patient rights information was provided to a patient's guardian/representative if that individual was not present to sign the documentation and speak with a registrar.

A Social Worker was interviewed on 4/19/12 at 9:10 AM. When asked how the hospital ensured guardians who were not present upon patient admission were given patient rights information, she replied "whatever registration does related to patient rights is what is done." She explained dispensing patient rights information was not the role of the social worker. When asked who communicated with the guardian, she stated the physician or charge nurse or case managers might call a guardian or DPOA if they felt it was needed.

Patient #1's legal guardian was interviewed on 4/18/12 at 2:50 PM. She confirmed that she was not able to be present at the time Patient #1 was admitted through the ED, but was in contact with hospital staff soon after the admission to discuss the plan of care. She stated she was not given information related to patients' rights and responsibilities even though she was involved in Patient #1's care and treatment throughout her hospitalization.

The "Patient's Rights and Responsibilities" policy, dated 10/12/10, was reviewed. The policy indicated "all patients admitted for care and service or their legal guardian, family or caregiver will receive verbal instructions and a written copy of patient rights information." The policy did not contain instructions to effectively ensure a patient's representative received the required patient rights information if the representative was not present at the time of the admission or did not have the opportunity to speak with a registrar to complete admission paperwork on behalf of the patient.

The Supervisor of Quality and Risk Management was interviewed on 4/18/12 at 1:15 PM. She reviewed the hospital's policies related to patient rights and acknowledged they did not include a process of how patients and/or caregivers/representatives would receive patient rights information if this did not occur with contact through a registrar. She stated she wanted to double check to confirm this, but had not produced additional information as of 4/19/12.

The hospital failed to establish and implement procedures to effectively ensure that patients' representatives had information necessary to exercise rights on behalf of the patient.

Based on review of medical records, hospital policies, and interview, it was determined the hospital failed to ensure personal information was not released to unauthorized individuals for 1 of 2 patients (#1) who had a legal guardian and whose records were reviewed. This resulted in personal health information being shared with individuals who had not been authorized by the legal guardian to receive information. Findings include:

Patient #1 was an 82 year old female admitted to the hospital on 11/16/11 for treatment of a small bowel obstruction (which required surgery to correct) and sepsis (an infection in the blood stream). Prior to hospitalization she resided in a SNF and was discharged back to the SNF on 11/30/11.

Patient #1's medical record indicated she was admitted to the hospital after an evaluation in the ED. Her medical record contained documentation transferred with her from the SNF including legal documents of appointment of guardianship and an "Admission Face Sheet" from the SNF. At the bottom of face sheet, the name and phone number of an individual had been written in. A hand written message next to this information referenced the individual and read, "Friend - Do not contact [with] [change] of status. [Name of guardian] is guardian."

Patient #1's medical record contained a "Conditions of Admission" document. The registrar signed this document, on 11/16/11at 1:04 PM, along with a second witness, and wrote "Pt [patient] unable to sign at all." There was no documentation to indicate the legal guardian was aware of the patient rights and responsibilities, including the right to limit the release of PHI on behalf of Patient #1.

PHI was disclosed to individuals without authorization of the legal guardian in the following examples:

- The RN documented on 11/25/11 at 4:28 PM that the family was educated on Patient #1's medications, pain, and the intravenous nutrition she received.

- The Speech Therapist documented on 11/26/11 at 3:04 PM that Patient #1's son, family friend, and nursing staff were educated on Patient #1's swallowing progress.

The legal guardian for Patient #1 was interviewed on 4/18/12 at 2:50 PM. She stated she was involved in the care plan and treatment for Patient #1 and had spoken freely with staff the first few days of Patient #1's admission. She stated she was not asked about who may or may not have authorization to receive PHI for Patient #1. She stated that during a conversation with nursing staff she became aware that a "friend" of Patient #1's had been receiving information about Patient #1's health status and the friend had notified Patient #1's son of the admission. According to the legal guardian, not only had the son been notified of the admission, but had come from out of state to become involved in Patient #1's care. The legal guardian stated she had not authorized these individuals to receive information and confirmed that staff had been disclosing information to the "friend" and the son until she requested this be discontinued.

RNs A, B, C, and D and LPNs A, B, and C were interviewed on 4/19/12 between 11:15 AM and 11:45 AM. They were each asked how they obtained authorization to discuss PHI with individuals other than the patient. Each stated, even if the patient had a legal guardian, they would ask the patient, provided they were able to respond, for verbal consent to share PHI. There was varying levels of interpretation of the role of a legal guardian but no one stated that they were aware that the legal guardian was responsible for making decisions for the patient, including the decision of who was authorized to receive PHI.

RNs E, F, and G were interviewed on 4/19/12 at 11:30 AM. Each RN confirmed they were not authorized to release PHI without consent from the patient. RN E explained that if the patient, who was unable to give consent, had a legal guardian, she would require proof of the legal guardianship and then allow the guardian to determine who was authorized to obtain patient PHI. RN F explained that if a patient was not confused and gave staff permission to share PHI with an individual, that consent was considered sufficient regardless of whether or not a patient had a legal guardian. She stated that she understood a legal guardian to make decisions on behalf of the patient when the patient was incapacitated.

The "VERIFICATION OF EXTERNAL REQUESTORS" policy, last reviewed 7/2006, indicated "Every member of the facility workforce must verity the identity of any person or entity when the person or entity is unknown to the workforce member and is requesting protected health information (PHI) either in person, verbally or via written request." The policy then outlined mechanisms to verify the identity of individuals, one of which was requiring a requestor to provide a "minimum of three information items" from a specific list.

The "USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION TO FAMILY MEMBERS OR FRIENDS FOR PATIENT CARE PURPOSES" policy, last reviewed 7/2006, was reviewed. According to the policy, "If the patient is present for or otherwise available prior to the use or disclosure and has the capacity to make health care decisions, workforce members with access to PHI may use or disclose the PHI if one of the following has occurred..." Except in emergent situations, the policy did not include direction to staff regarding who may determine and provide authorization for release of PHI when the patient did not have the capacity to make healthcare decisions and required a representative such as a legal guardian.

The facility failed to ensure that a legal guardian had authorized the disclosure of personal health information to specific individuals.