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Based on facility documentation review and interview, the facility failed to ensure the Power of Attorney received a patient's record in a timely manner for one (#3) of five patients reviewed.

The findings included:

Medical record review revealed patient #3 was admitted to the facility on March 12, 2012, and expired on March 25, 2012, with diagnoses to include Extensive Lung Cancer, Stage 4; Community-Acquired Pneumonia; Adult Respiratory Distress Syndrome; Chronic Renal Insufficiency; Chronic Obstructive Pulmonary Disease; and Right Internal Jugular Vein Thrombus. Continued review revealed the patient had undergone chemotherapy and was on an investigational medication.

Interview with the Director of Quality Improvement (QI) on September 10, 2012, at 12:30 p.m., in the administrative conference room, revealed the spouse had requested a copy of the patient's medical record in two letters written to the QI department, with the initial request being May 6, 2012.

Interview with the Director of Health Information Management on September 10, 2012, at 3:00 p.m., revealed the department had received the spouse's request for a copy of the medical record. Continued interview revealed the request was normally forwarded to the out-sourcer who arranged for copies of medical records. Further interview confirmed no documentation the request for copies of the medical records had been sent to the out-sourcer nor was there documentation of any follow-up by a member of the Health Information Management department.

Based on review of facility documentation and interivew, the facility's medical record department failed to ensure the process for obtaining medical records was followed for one (#3) of five patients reviewed.

The findings included:

Medical record review revealed patient #3 was admitted to the facility on March 12, 2012, and expired on March 25, 2012, with diagnoses to include Extensive Lung Cancer, Stage 4; Community-Acquired Pneumonia; Adult Respiratory Distress Syndrome; Chronic Renal Insufficiency; Chronic Obstructive Pulmonary Disease; and Right Internal Jugular Vein Thrombus. Continued review revealed the patient had undergone chemotherapy and was on an investigational medication.

Interview with the Director of Quality Improvement (QI) on September 10, 2012, at 12:30 p.m., in the administrative conference room, revealed the spouse had requested a copy of the patient's medical record in two letters written to the QI department;.

Interview with the Director of Health Information Management on September 10, 2012, at 3:00 p.m., revealed the department had received the spouse's request for a copy of the medical record. Continued interview revealed the request was normally forwarded to the out-sourcer who arranged for copies of medical records. Further interview confirmed no documentation the request for copies of the medical records had been sent to the out-sourcer nor was there documentation of any follow-up by a member of the Health Information Management department.