HospitalInspections.org

Based on clinical record review, facility policies, and staff interview the facility failed to follow their policy #1000.01 titled, "Patients Rights and Responsibilities" when the facility staff failed to correctly execute their Release of Information form (ROI). The patients' mother signature was obtained in error on the ROI (Release of Information) form.
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Findings included:
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Facility policy #100.11 entitled Admission of Patient To The Facility, Reviewed: 06/15/2016 page 2 reads in part, "The RN or designated staff member will ask for a consent from the patient regarding notification of family members and/or significant others of the hospital admission."

Facility policy #520.00 entitled Privacy And Security Guidelines, Effective: 7/7/14 page 1 reads in part, "#2 All patient information is considered confidential and may not be released to anyone without prior written consent from the patient or legal representative or pursuant to a valid court order. Patient information is defined as any written, electronic or verbal information about a current or former patient that is personal and private in nature, including his or her existence in treatment (including whether he or she is, or ever was, an inpatient or outpatient)."

Facility policy #1000.01 entitled Patient Rights and Responsibilities, Revised: 05/19/17, included the following: #12. "Obtain information on disclosure of protected health information, in accordance with federal, state and local law.
#14. Have a family member or representative of his/her choice notified promptly of his/her admission to the hospital if permission is given on the Release of Information form.
#15. Have a family member, friend or other individual be present for emotional support throughout the course of stay if permission is given on the Release of Information

Review of the patient's clinical record revealed the Release of Information document was signed by the patient's mother instead of the patient during the admission process intake assessment. The Intake unit staff signed the ROI document as well. Intake Assessment forms page #5, indicated the release of information was approved for the patient's mother and father. The patient's mother request patient information on several occasions, but was told that there was no ROI. Staff did not ask patient if he was willing to sign an ROI for his mother until the day before the patient was discharge from GBHI.

In an interview with the Staff #3 she was asked why the patient was not asked to sign the ROI when the patient's mother called asking for information about her son. Staff #3 stated, "I don't know."

The above findings were acknowledged by the Staff #3 on the afternoon on 10/31/17.