HospitalInspections.org

Based on record review and interview, the facility failed to furnish a true and correct copy of all of the patient's records to SP#1's personal representative designated by the patient in writing for 1 (SP#1) of 3 sample patients (SP).

Findings include:

SP#1 was discharged from the hospital 08/27/2021.

Review of the Authorization for Release of Confidential Medical Records signed by SP#1 on 8/26/2021. Further record review revealed that the form was faxed to the Health Information Management (HIM) department on 8/31/2021 by the family member.

Review of the STAT Informatic Solutions-Release of Information letter to Medical Records/STAT on 9/22/2021 documented, "Unfortunately, we cannot complete your request at the present time for the following reason: MISSING DATE OF BIRTH".

Review of policy No. MR-RI, Section: HIM Release of Information, Subject: Authorization for Release of Confidential Information, Reviewed 04/2017 documented, "I. Record Completion: a. It is preferred that the patient's records be released within 10 days of a written request regardless of completion. Therefore, the record should be completed as quickly as possible in order to release it within the 10-day period."

Interview with Staff H, Director of Regulatory Affairs on 1/13/2022 at 11:51 AM revealed, "Records were not sent." Staff H provided a copy of the form faxed to Health Information Management dated 1/12/2022. Staff acknowledged on 1/12/2022 that the request was not completed.