HospitalInspections.org

Based on interview, record review and a review of facility documentation, the facility failed to ensure that the patient's right to access of information in the form of a complete medical record as requested was fulfilled for 5 of 5 sampled residents who had submitted post-discharge requests for complete records (#1, 11, 12, 13 & 14).

Findings:

Reviews of the records of patients #1, #11, #12, #13 and #14, in which requests were made for complete records after patient discharge revealed the following.

1. The request for patient #1's medical record indicated a request form dated 2/09/16 and resulted in 807 pages being provided.

2. The request for patient #11's medical record indicated a request form dated 3/22/16 and resulted in 38 pages being provided.

3. The request for patient #12's medical record indicated a request form dated 3/24/16 and resulted in 26 pages being provided.

4. The request for patient #13's medical record indicated a request form dated 3/17/16 and resulted in 19 pages being provided.

5. The request for patient #14's medical record indicated a request form dated 3/16/16 and resulted in 36 pages being provided.

During an interview of the Director of Health Information Management (HIM) on 4/01/17 at 10 AM, he stated that the actual amount of pages in the medical record for each patient was higher than the provided amounts as stated above. He provided documentation which showed that the total number of pages in each medical record were as follows:
for patient #1, it was 3,263, for patient #11, it was 159, for patient #12 it was 133, for patient#13, it was 610, and for patient #14, it was 285. He stated that he had learned that the staff member at their HealthPort vendor who was assigned to Osceola Regional Medical Center had been sending out abstracts instead of complete records when requests for complete records had been submitted. He stated that the vendor employee had been trained to do so by supervisory personnel. Thus, the requests that had been made for complete records of the above mentioned patients were not fulfilled.

During an interview of the Director of HIM at the above stated time, he confirmed the findings. During an interview of the Director of Quality on 4/01/16 at approximately 1:30 PM, she confirmed the findings.