HospitalInspections.org

Based on medical record review, interviews and review of policy and procedure, the hospital failed to provide a copy of Patient Identifier (PI) # 1's medical record to the patient's family as requested and in accordance with the hospital's Patient's Rights policy and procedure.
This deficient practice affected PI # 1, one of ten sampled patient records.

Findings include:

Medical record review reveals that PI # 1 was admitted to the hospital on January 10, 2011, with diagnoses that include Extremity Cellulitis, Ischemia, End Stage Renal Disease, History of Hypertension and Diabetes.

II. Interviews:
During an interview on 5/17/2011 at 5:00 PM, the Chief Executive Officer (CEO)/ Employee Identifier (EI) Number # 1 said a letter requesting a copy of PI # 1's medical record from PI # 1's family, was received in Administration on 4/27/2011. The letter documents the family received a letter from the hospital on 4/4/ 2011 informing them that PI # 1's Power of Attorney was not valid regarding authorization to receive a copy of the medical record.

According to the CEO/ EI # 1, this letter was forwarded to the hospital's legal staff who determined PI # 1's Power of Attorney was not valid after PI #1's death.

During an interview on 5/20/2011 at 12:15 PM, the Hospital's General Counsel / EI # 2 stated PI # 1 had a General Power of Attorney (POA) regarding basic business decisions that ended at the time of PI # 1's death. Prior to PI # 1's death, physician certification had to accompany the family's request for the medical record. This certification was not part of the family's request on 3/2/2011 and the medical record was not released.

During an interview on May 26, 2011 at 8:30 AM, PI # 1's daughter said she made multiple requests to obtain PI # 1's medical record from the hospital. However, she did not receive a copy of the medical record until May 23, 2011. According to PI # 1's daughter, PI # 1 expired on 3/23/2011. PI # 1's daughter denied that any hospital clinical staff offered her the opportunity to review PI # 1's medical record with the patient's primary physician during PI # 1's hospitalization.

III. Review of Memorandum and Policy and Procedure:
The Hospital's General Counsel / EI # 2 provided a written memorandum (dated 5/20/11) regarding PI # 1's Power of Attorney (POA). "A POA must be specific in that powers that are granted...the specific powers must be stated and specified in the document." In PI # 1's POA, "...General business decisions were granted,...but the POA has no specific health care decisions/authority language other than the restricted health information provision." According to the memorandum PI # 1's POA, "Had a restricted power to obtain information about the physical or mental condition of the grantor of the POA, but such request had to be accompanied by a statement, endorsed by proper physician certification of my (PI # 1's) disability or incapacity. The original request did not contain the required physician certification and was therefore invalid. The POA was subsequently nullified altogether by (PI # 1's) death."

Policy and Procedure: Patient Rights: Confidentiality, Right to Privacy, Security and Integrity of Information. Issue Date: 12/83, Revision Date: 6/08, Review Date: 3/09. "...J. 3. Medical information may be released only on written authorization from the patient, the patient's legal guardian, if the patient is a minor or mentally incompetent, a subpoena, a court order, or statute must be presented to the Health Information Management department prior to records being released. In case of death, the authorization must be signed by the patient's next of kin or specified executor of the estate"

According to the hospital's policy, PI # 1's next of kin was eligible to receive a copy of PI # 1's medical record after PI # 1's death on 3/23/2011. However, the hospital failed to provide a copy of PI # 1's medical record to the family until May 23, 2011, 61 days after PI # 1 expired.