HospitalInspections.org

Based on staff interviews and review of facility documents, it was determined the facility failed to ensure that policies and procedures that address written communication with complainants are implemented.

Findings include:

On 10/17/2023 at 9:40 AM, Staff #2 (S2),Vice President (VP) Quality and Safety, confirmed that Family Member #5 (FM5) filed a complaint with the facility. He/she provided the facility's complaint investigation, upon request. The facility investigation documentation lacked the final facility letter, mailed to the complainant, as required by the facility policy below.

Upon interview on 10/17/2023 at 1:55 PM, S2 confirmed the facility contacted the complainant via telephone only and failed to send a written response to the complainant when the investigation was complete.

Reference: Facility policy titled "Patient Complaint and Grievance Management Process" last reviewed May 2022, states, "...Formal response: Is written communication provided by an authorized facility representative in response to grievance...d. Letter will be sent to the complainant when the investigation is complete. The letter will include a summary of the findings and actions taken by the facility (when applicable) to resolve the grievance. If the grievance cannot be resolved within the 7 business day timeframe, an additional letter will be sent..."

Based on document review and staff interviews, it was determined the facility failed to ensure the confidentiality of a patient's medical record.

Findings include:

On 10/17/2023 at 10:50 AM, a tour of the medical record department was conducted. At 10:55 AM, during an interview with Staff #13(S13), Health Information Specialist, explained the process to receive a copy of a medical record. S13 stated that all requests for copies of medical records should be made in writing and directed to the Health Information Management Department. S13 stated that a complete copy of medical records could be provided to the requestor within 30 days. However, in cases of urgent need, a medical abstract report could be provided on the day of request.

On 10/17/2023 at 2:00 PM, S2, Vice President of Quality and Safety, stated that medical record department staff are from CIOX, a vendor the hospital has a contract with.

Review of the incident report, dated 07/18/2023 stated, "[mother's name] of Patient #3 (P3) had requested medical records to be faxed to her son's physician and for her to pick up, completed on July 18. However, she was sent home with P4's medical records." This was confirmed by S2 on 10/17/23 at 2:00 PM. S2 provided a copy of the facility incident report and the Plan of Correction submitted by CIOX for review. The investigation conducted by CIOX discovered the staff member failed to follow policies for verifying patient information prior to releasing the medical record abstract.

On 10/17/2023 at 2:00 PM, S2 confirmed the facility's policy and procedure was not followed and P3's parent received P4's information.